Incident investigation·June 6, 2023

On 6/6/2023 at 10:20 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit regarding an incident report received on 5/20/2023. LPA met with Gigi Tamayo (RN) and explained the purpose of the visit. Incident report dated for 5/18/2023 revealed that Resident 1 (R1) reported ingesting calligraphy ink during facilities activity. RN stated that resident was doing calligraphy as part of resident’s activity in the facility. S1 informed RN that the resident had black ink all over her hands and mouth. S1 observed resident's hands and mouth with black ink, S1 asked S2 to help clean resident’s hands and mouth, and S3 informed RN about the incident. Facility staff took R1's vital signs and assessed her if R1 had any pain from ink. Facility called 911 for further evaluation. R1's representative was notified, poison control was notified and RN stated that poison control could not find much information if the ink was harmful to ingest. R1 returned to the facility on 5/18/2023 with no concerning health issues. LPA collected the following documents: After visit summary, and Physician's visit report form. No deficiencies cited during visit. Exit interview conducted with RN and a copy of this report provided.