Incident investigation·May 5, 2022

At 11:30 a.m. on 05/05/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with Administrator and disclosed the reason for the visit. The reason for the visit comes from an incident report submitted on 05/04/2022. Resident #1 (R1) was admitted on 04/29/2022 with pressure injuries on the buttocks and left heel of unknown stages. During a 04/28/2022 hospital visit, a Kaiser physician informed the R1 and R1’s family that the wound on the heel would not prohibit admission to a board and care. The physician did not disclose the size or stage of the wounds but arranged a 05/05/2022 podiatry appointment. Home health also evaluated the wounds on 05/03/2022, but additional follow up was required for staging and treatment. Regional Office has requested a full investigation by the Investigations Branch. The referral is currently pending. At approximately 12:30 p.m. LPA interviewed Administrator. At 12:51 p.m. LPA conducted a record review. LPA obtained copies of the register of facility residents, personnel report, staff training records, and medical assessment. Administrator will send additional information through email later today. At 1:20 p.m. LPA and 2 Administrators conducted a physical plant tour with Administrator. R1 was in bed in an elevated position. R1 was safe and in good health. Administrator and staff redressed the wound. 2 photographs of the wound were taken. Exit interview conducted. Copy of report provided.