Incident investigation·May 22, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to follow up on an incident report submitted to the Department on/around May 15, 2025 for an incident that occurred on May 13, 2025. LPA met with Director of Nursing (DON), Karen Padilla, and stated the reason for today's inspection. LPA discussed the incident more with the DON, who confirmed that resident (R1) was observed to have a paring knife in their room on May 13, 2025. The DON stated (R1) moves around the facility a lot but is not sure if the resident moved in with the knife, as it was wrapped in a paper towel, or it was obtained form the facility kitchen. The incident report submitted states that (R1) pulled a knife out to a Med-Tech staff (S1) and stated they are "stressed out". A second Med-Tech (S2) immediately intervened and asked that resident give the knife to her, which the resident refused to do a few times. The incident was then reported to the DON, who suggested resident be sent out for further medical evaluation. Resident was sent out and hospitalized overnight, returning the following day at 3:40 pm. Multiple lab tests were performed, including liver ultra sound, and the ammonia level, which all returned within normal limits. Additionally, a psych test was done which approved resident to return to the facility on 5/14/25, but with medication changes made. LPA reviewed facility documentation which shows (R1) has a diagnosis of dementia and can display aggressive, wandering and sundowning behaviors. Facility has increased monitoring for (R1) and will install code locks for the kitchen doors to ensure resident does not have access to the kitchen. Per Title 22 Regulations, Division 6, Chapter 8, the following deficiency is cited on 809-D page. Exit interview. Copy of report and appeal rights provided.