Follow-up·December 1, 2022

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Other inspection at the facility due to a Civil Penalty not being assessed during complaint investigation control number 29-AS-20220104110534. The LPA met with Administrator Jennifer Shaffer. Entrance interview conducted. It was revealed during the course of the investigation, that although Resident #1 (R1) had three (3) pressure injuries when admitted to the facility. R1 developed additional pressure injuries while in care. On 6/24/2022, LPA Arroyo substantiated allegation: resident developed pressure injuries while in care as R1 was reassessed after 90 days of being admitted to the above facility and was noted to have new wounds which included one (1) unstageable pressure injury on the right malleolus and two (2) stage 3 pressure injuries on the right hip and on the right buttock. Additionally, facility was cited on a separate case management-deficiencies on 6/24/2022 for admitting and retaining R1 in the facility with a stage 3 or higher pressure injury without being on hospice and there were no records indicating that an exception request was submitted in order for R1 to be admitted or to remain at the facility. Civil penalties in the amount of $500 is being assessed today for citation previously issued on 6/24/2022 for deficiency 87615(a)(1) – Prohibited Health Conditions. Due to a glitch in the system, the LIC 421IM for the immediate $500 civil penalty was unable to be assessed through citation previously issued on 6/24/2022 and therefore, will be issued manually. Exit interview. Appeal Rights discussed. Copy of the report provided to the Administrator via email.