Facility Evaluation Report

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 7/28/26 to do case management visit . LPA met with Staff, RN, Erica Self and explained the purpose of the visit.

Department followed up on Incident Report (IR), LIC624 sent by facility on 7/21/26 stating that on 07/20/26, resident R1 grabbed medication bottle of Gabapentin 300mg from staff S1 when S1 was preparing R1s evening medications around 6:25PM. IR stated that R1 put handful of Gabapentin 300mg pills on their hand and put approximately 13 pills in their mouth and attempted to in digest it. It was learnt that staff called emergency services 9-1-1 immediately after this incident and R1 was sent out to get the required medical care at local hospital. Record review reflected that R1 was put on 5150 Hold at the hospital and went through psychiatric evaluation. R1 did not return to the facility after this incident.

Facility notified R1s physician and other required agencies regarding this incident.

During today’s visit, the Department conducted interviews with staff

At this time, this case in under review and department will do follow up as warranted.

No citations were issued per Title 22 Regulations.

Exit interview conducted and copy of the report left at facility.