complaint·October 15, 2021

Facility records did not show any documentation of R1’s history of depression or suicidal ideations. R1’s medical records indicated that R1 was not on anti-depressant medication. Police report, coroner’s report, and death certificate were also reviewed. Police report noted the interview of R1 stating R1 no longer wish to live and a suicide note written by R1 was confiscated by the police officer on scene. Documents and interviews suggest that facility staff were unaware of R1’s depression and suicidal ideations. The facility did not have medical records that documented R1’s prior suicide attempt. Once aware of R1’s depression and suicidal tendencies, R1’s room was searched for unsafe items. The facility hired a personal companion to stay with R1 24 hours a day when R1 returned to the facility. The Department has investigated the above allegation. Based on interviews and records reviewed, the Department found the above allegation is UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No deficiencies were cited during today’s visit. This report was reviewed with Kris Waluszko, Interim-Executive Director, and a copy was provided.