complaint·June 22, 2021

Allegation: "Resident had access to cleaning supplies while in care resulting in hospitalization." Based on record review and interviews conducted the findings revealed that on 12/19/2020 at approximately 11:45 PM Dementia resident (R1) found a 16 ounce hand sanitizer bottle and drank it. The resident resided in the Memory Care unit of the facility. At that time the facility had a COVID-19 outbreak that required infection control supply carts in COVID-19 areas that were equipped with personal protective equipment (PPE). The hand sanitizer was inside the drawer of the isolation cart that did not have a lock. One staff witnessed the incident and called 911 emergency. The resident was transported to Greater El Monte Community Hospital and treated for accidental ingestion. Items that could constitute a danger must be stored inaccessible to Dementia residents. Staff interviews confirmed the incident. Per staff interviews, there were staff shortages at the time of the incident due to the COVID-19 outbreak at the facility. Staff were working 12-hour shifts in the Memory Care Unit. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to California Code of Regulations, Title 22. See LIC 9099D. An exit interview was conducted and Plans of Correction were reviewed and developed with Business Director. A copy of the report and appeal rights were discussed and left with Business Director Haigaz Kazazian.