Incident investigation·April 25, 2022

On 04/25/2022 at approximately 9:05am Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a case management visit regarding a self-reported incident that occurred on 04/05/2022. LPA met with Administrator Cecily Palma and explained the purpose of the visit. During the visit, LPA obtained relevant documents and interviewed Administrator. 2/3/22, Resident (R1) was admitted to facility from a Skill Nursing Facility. 2/9/22, R1 started receiving home health service due to physical therapy through Neogen Home Care. 2/18/22. Home care services was discontinued of visiting resident, but service was still active. 3/21/22, Redness on R1's buttocks area was noticed, Administrator notified Neogen Home Care, Neogen sent nurse (W1) to visit R1 on the same day. R1's POA and physician were notified. 3/23/22, Nurse (W1) revisited resident and determined the wound was stage 2. Home health nurse provided wound care services to R1 two times per week. 4/4/22, Nurse (W1) noticed the wound became stage 3, R1 was sent to hospital for treatment. Administrator stated that R1's POA and physician were notified. 4/7/22, R1 was admitted to skill nursing facility after discharging from hospital. R1's wound has not been getting better during the time from hospital to skill nursing facility. 4/19/22, Skill Nursing facility submitted request to initiate hospice service for R1 due to Degenerative Disease of Nervous System. Suncrest delivered an APP air mattress to facility for R1. 4/20/22, R1's hospice service was initiated through Suncrest Hospice. R1 was requested to return to facility per POA. Administrator stated that hospice nurse arrived at facility before resident returned. 4/20/22, Administrator updated Needs and Service Plan for resident. No deficiency cited during visit. Exit interview conducted with Administrator and copy of this report provided.