Incident investigation·November 2, 2022

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a follow-up on an incident report that was received on 10/31/2022 for Resident #1 (R1). LPA met with John Brennan, Executive Director who was informed of the purpose of the visit. During the visit LPA reviewed R1's file, interviewed staff and gathered documentation pertaining to the incident report. LPA observed that progress notes were documented on 10/13/2022 and again on 10/14/2022 for home health to check R1 for a wound. LPA observed on 10/25/2022 this visit was conducted and R1 was transferred to hospital. It was found through interviews that there were no prior reports to 10/13/2022 for the incident reported or documented for a wound. It was also found that the resident was appraised for hospice services after 10/25/2022. The resident was not on hospice or Home health services prior to 10/25/2022. LPA reviewed documentation for progress notes on 10/25/2022 stating that the wound was unstagable. Therefore based on the above, the facility will be cited for failure to reappraise resident for change in condition. This will be documented on an LIC809-D page along with the plan of correction. An exit interview was conducted were this report along with 809-D page, and appeal rights were reviewed and provided to executive director, John Brennan.