Facility Evaluation Report

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.