Facility Evaluation Report

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced case management visit to deliver findings for an investigation that was initiated based on an incident originally reported to the Department in June of 2025. LPA Correia was greeted by Med-tech Madla, identified herself, and met with Administrator Drummond to whom it was explained the purpose for the visit.

On June 24, 2025, the Department received a Special Incident Report regarding the hospitalization of a Resident (R1), who was found to have suffered an apparent medication overdose on the morning of 6/19/25. After a subsequent Health and Safety visit revealed R1 had a known history of suicidal ideation, the Department initiated a full investigation to determine whether facility neglect contributed to the incident.

The Department’s investigation included a review of facility and hospital records, as well as interviews with staff and outside sources, including medical professionals and law enforcement.

R1’s facility records indicated that they were admitted to the facility in November of 2024 with previous diagnoses that included suicidal ideation, Major Depressive Disorder, and bipolar disorder. Records found in the facility from R1’s prior Skilled Nursing Facility (SNF) corroborated that R1 had a history of suicidal ideation and required extensive assistance with Activities of Daily Living (ADLs), Medication Management, Safety Monitoring, and oversight of overall health status. A review of R1’s Hospice Care Plan dated 6/2/2025 and applicable through 6/23/2025 listed several comorbidities which included depression, and suicidal ideations. According to their pre-placement Appraisal conducted on 11/25/24, R1 had depression, and required assistance with medications, and observation for pain or depression.