Incident investigation·July 6, 2023

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection LPA met with Jason Geron, caregiver and explained purpose of inspection. LPA met with Administrator Designee, Russelle Robinson, who arrived shortly. Also present was caregiver, Nicole Davis. There are currently (5) residents and (1) resident under hospice care. LPA and Administrator discussed the incident report submitted to the Department on 6/27/2023 reporting R1's admission to the hospital on 6/26/2023, per home health recommendation, for a wound on the right heel not improving despite resident taking oral antibiotics and more frequent wound dressing changes. Incident report submitted on 6/30/2023 reports resident being discharged back to the facility on 6/28/2023 after being placed on hospice on 6/29/2023, and refusing an above knee amputation due to a bone infection. LPA reviewed resident's file, including pre-admission paperwork from skilled nursing, physician's report, After Visit Summary for hospitalization (on 6/28/2023) and hospice paperwork. Pre-admission documentation, including the physician's report, notes resident had a pressure ulcer on the right heel prior to being admitted to the facility on 5/6/2023 and while residing at skilled nursing from 4/16/2023 through 4/28/2023. Resident was discharged from skilled nursing on 4/28/2023 and went back to his residence before being admitted to the facility on 5/6/2023. Medical documentation, dated 6/28/2023, shows wound care for diabetic ulcer of right heel is to be changed daily and to discuss vascular surgery if resident wants to pursue as a non-hospice option. Resident receives hospice wound care from LVN/RN's approximately every other day. Administrator indicated that the wound on resident's right heal has been chronic and due to poor circulation, led to an infection in the bone that was recently discovered from a scan. Administrator stated staff continue to place pillows under both heels per prior home health orders. LPA observed resident to be resting in their bed with heel protectors on both feet, and to be in good spirits after lunch. There are no deficiencies being cited. Exit interview. Copy of report provided to Administrator.