complaint·May 1, 2025

Between 11:00am – 1:00pm, LPAs conducted interviews with the Executive Director, Memory Care Director, Health Care Director, three (3) staff/caregivers, six (6) out of forty-five (45) residents residing at Assisted Living, two (2) family members of residents residing at Memory Care unit and attempted to speak with six (6) out of 15 residents residing at Memory Care unit. Allegation: Staff do not ensure that hazardous items are inaccessible to residents in care. It was alleged that on 4/6/2025, R1 who resides in the Memory Care unit ingested dishwashing soap that was left on the kitchen counter. To investigate this allegation, LPAs conducted interviews with Executive Director and Memory Care Director and both parties interviewed confirmed that S1 diluted dishwashing soap “Dawn” in water and placed the container in the memory care unit kitchen counter unsupervised. During investigation, LPAs reviewed R1’s Physician’s Report (dated on 10/21/2024), where indicated (in Mental Condition section) Confused/Disoriented, Wondering Behavior and At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items due to Dementia. ED and MCD also confirmed that R1 had several episodes of wondering around the MCU during the nighttime. Although, no witnesses were present during the incident, the ED stated that when R1 was taken to the hospital on 4/6/2025 and discharged on the same day, both ED and MCD witnessed that R1 vomited soap like solution that was similar to bubbles. Moreover, during the interview with S1, S1 admitted that because he/she had to do scheduled residents check-up rounds, the mix of dishwashing soap “Dawn” and water was left unattended and accessible to R1. Review of the facility Incident Report revealed that R1 ingested unknown substance consisting of dishwashing soap and water, 911 was immediately contacted and R1 was transferred to the hospital. Lastly, review of Plan of Operation for Dementia Care specifies on page 13, under Safety and Storage of Hazardous Materials: "The materials that may pose a risk to residents, whether through contact or ingestion, are stored securely in locked areas and remain inaccessible to residents. This includes, but not limited to: Laundry and cleaning supplies...". Review of "Dawn" detergent, the Warning label specifies the following, " Warning: Causes eye irritation, do not get in eyes. Keep out of reach of children. Rinse hands throughout after handling. First Aid treatment contains anionic and nonionic surfactants. If in eyes: Rinse cautiously with water for several minutes. Remove contact lenses if present and easy to do. Continue rinsing for 15 minutes. If eye irritation persists: Get medical attention. If swallowed, drink a glass of water to dilute". Also, review of training records confirmed that Hazardous Chemicals course was provided and completed by S1 on 12/23/2024. Therefore, based on interviews and records review this allegation is Substantiated. Exit interview conducted and copy of this report delivered.