Facility Evaluation Report

On 10-14-2025 at 1:45pm, Licensing Program Analysts (LPAs) Michael Bilger and Sommer Hayes arrived unannounced to conduct a case management visit regarding recently reported incidents by facility. LPA met with Administrator Muhammad Qureshi and explained the purpose of the visit. LPA reviewed incident reports dated 10-7-2025 and 10-9-2025 in addition to current behavior intervention plan for resident1 (R1).

Incident report #1: On 10-7-2025, R1 was sent to hospital due to complaints of difficulty breathing. According to incident report, while R1 was in the hospital, R1 made statements of wishing to harm self. R1 was discharge back to facility on 10-8-2025 with no new medication orders and was monitored by staff.

Incident report #2: On 10-9-2025, R1 was sent to mental health hospital after an episode in which R1 stated she was going to choke herself while wrapping a clothing garment around her neck.

At this time R1 remains in mental health hospital for treatment and observation. A review of R1's behavior intervention plan revealed current behaviors addressed including self injurious behaviors. On-going interventions are in place and noted to accompany noted behaviors. A current 1:1 is assigned to R1 for safety and additional supervision. Facility staff records behavior data for tracking purposes and needs for any update to behavior intervention plan.

As a result of today's case management, no citations are issued. An exit interview was conducted with Administrator and a copy of this report was provided.