Incident investigation·June 18, 2025

On June 18, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 5/31/25. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit. The Licensee reported on 5/31/25, the med-tech went to Resident 1's (R1's) room around 7:45pm and R1 reported to the med-tech that he/she took over seven days of medication at one time. R1 told to the med-tech that he/she wanted to hurt himself/herself because he/she was feeling depressed. According to the Licensee, R1 resides in the assisted living community and manages his/her own medications. 911 was immediately called and all required parties were notified. R1 was admitted at the hospital for psychiatric evaluation. During the visit today, LPA interviewed the Administrator, Health Services Director, and Resident Care Coordinator, and reviewed R1's file. R1 was admitted to the facility on 5/21/25 and based on the physician's report dated 5/21/25, R1 was able to manage his/her own prescription and PRN medications and did not show any signs of suicidal ideations. Based on the new physician's report dated 6/11/25 (after incident occurred), R1 has a diagnosis of early onset of Alzheimer's dementia, and is unable to manage his/her own medications. According to staff interviewed, R1 returned back to the community on 6/16/25 and a 1:1 caregiver was implemented throughout the day for 72 hours. Facility staff are conducting status checks. R1 is seeing a psychiatrist and going to behavioral therapy session 5 days a week. Facility is now managing R1's medications and a new reassessment has been conducted. No citations are issued today. Report is reviewed with Administrator and a copy is provided.