Incident investigation·June 16, 2025

On 6/16/2025, Licensing Program Analyst Janette Romero conducted an unannounced case management visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted by the facility reporting an incident involving Resident 1 (R1). LPA met with Administrator, Marie Hill who was informed of the purpose of the visit. The LIC 624 reported the following information. On 2/28/2025, R1 was found in their room with a container of Powdered Chlorine Bleach Cleaner (PCBC). R1 applied the cleaner onto their hand and face and a "small" amount was found in their cup of water. When asked if consumed, R1 initially reported they did and then denied doing so. The facility called an ambulance and R1 insisted on having dinner. R1 ate their dinner in the dining room with no complaints or reports of pain/discomfort. R1 was taken to the hospital via non-emergency medical transport and later returned to the facility with no new findings. Administrator Hill was interviewed and reported the following information. The disinfectants/cleaning solutions are stored in the locked laundry room inside every housekeeper's locker. The lockers are individually secured with a keyed padlock. When in use, housekeepers transfer the disinfectants/cleaning solutions onto their mobile carts, which also have a locking mechanism to make it inaccessible to the residents in care. Hospital records indicate the correct date of the incident is 2/27/2025 not 2/28/2025. On 2/27/2025, the incident took place as documented in the LIC 624 noted above. Housekeeping Staff 1 (S1) was assigned to clean R1's bedroom. Administrator Hill interviewed S1 regarding the incident and received following information. S1 used the PCBC to clean R1's room. After cleaning R1's room, S1 only secured one (1) PCBC as they did not realize they had two (2) PCBCs in their cart. S1 admitted to accidentally leaving one (1) PCBC unattended in R1's bedroom, which made it accessible to R1. Administrator Hill was made aware of the incident when R1 was having dinner. Facility staff measured R1's vital which were not abnormal and R1 did not exhibit any signs of distress. Therefore, the facility arranged for non-emergency medical transportation to the hospital. During today's visit, LPA toured the facility and observed the 21 ounce containers of PCBC used by housekeepers. LPA also observed the lockers with padlocks, mobile carts with locks, and laundry room which required a keyed fob entry. LPA observed the ounce PCBC container titled, "Cleanser Powerful Cleaning Action with Chlorine Bleach" and warns users to use protective gloves and eye protection as it causes skin, respiratory, and serious eye irritation. LPA reviewed R1's Physician's Report dated 8/27/2024 noting R1 exhibits confusion, is oriented to self only, and does not have the capacity to leave the facility unassisted, manage their own cash resources or medications. During today's visit, no imminent health or safety concerns were observed. Based on the aforementioned, the facility will be cited and civil penalties will be assessed. An exit interview was conducted, and a copy of this report, LIC 809-D, LIC 412FC, and Confidential Names list (LIC 811) were reviewed and provided to Administrator Hill.