Incident investigation·April 15, 2026

On April 15, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management in relation to an incident that occurred on 4/11/2026. LPA met with Acting Administrator, Nick Catalano and explained the purpose of the visit. On April 11, 2026, Resident 1 (R1) was observed in another resident's shared room (R2's and R3's) room. R1's caregiver went to re-direct him/her and was observed chewing on a bar of soap. Caregiver immediately brushed R1's teeth. R1's lips became swollen. 911 was called and R1 was transported to the hospital. During the visit, LPA reviewed R1-R3's file. Based on R1-R3's file reviewed, all three residents have a diagnosis of dementia, however according to the physician all R1, R2, and R3 are not at risk if allowed access to personal care and hygiene items. According to the acting administrator and resident care coordinator, the bar soap was R2's bar soap. All chemicals, toxins, and sharps should be locked and inaccessible to residents in care, however for this case, R2's family comes in and out of the facility and brought R2 soap without telling staff. Staff did not observe the soap in R2 and R3's room. During the visit, LPA observed chemicals and toxins locked and inaccessible in the storage room. Acting administrator indicated he is going to discuss the incident with R2 and R3's family and send an email to families notifying them to let staff know when personal belongings are being brought into the facility. Based on records reviewed, this is the first time R1 has shown at risk behaviors if he/she has access to personal care and hygiene items. R1's service plan was updated. No citations are issued during the time. Report is reviewed with Nick Catalano and a copy is provided.