Incident investigation·April 16, 2021

On 04/16/2021, Licensing Program Analysts (LPA) Leslie Ibo conducted a Case Management Health with Administrator Kaitlyn Clarey and nurse Margaret Hsu, in relation to the incident report submitted on 4/1/2021, R1 was diagnosed with C-Diff, per facility policy they can’t provide care for resident with c-diff, another incident report R2 was sent to Emergency room for un-stageable wound. LPA explained that due to Shelter in Place Order and directive from management to telework, inspection will be done via phone call. During the interview with Administrator and Nurse, R1 was sent to skilled nursing for c-diff treatment and back to the facility on 4/4/2021. R2 has a regular home health nurse visit and wound nurse that is routinely check resident’s both legs, 02/20/2021 wound nurse examined R2’s legs and saw redness on right feet, per facility nurse (Margaret Hsu) it wasn’t reported to her, R2 has a wrapped around on both legs and wound care nurse is the one checking on any signs of wounds , on 03/26/2021 wound care nurse HH1 determined that wound is unstageable. Facility nurse then send out resident to ER for further evaluation. On 04/15/2021 a surgical debridement was done for R2 will be transferred to skilled nursing. LPA will need to conduct follow up visit, LPA requested for documents such as home health nurse notes for R2. Margaret Hsu agreed to send the requested document via email. Exit interview conducted. Appeal Rights and a copy of this report emailed.