Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by the Concierge and explained the purpose of the visit.

During the Department’s investigation for complaint control # 22-AS-20250218081, the following was discovered:

Resident #1 (R1) was admitted to the facility on November 24, 2022, and resided in Memory Care. Per Physician report dated October 31, 2024, R1 had a diagnosis of Hydronephrosis with renal and ureteral calculous obstruction, sepsis and Mild Cognitive Impairment. Physician report further assessed R1 was non-ambulatory and a maximum assist for all self-care needs and activities of daily living.

On December 4, 2024, facility progress notes document that, “the resident’s left heel is noted with a small purple/red discoloration non-blanchable. The care team was instructed to reposition resident every two hours, elevate the resident’s legs and support R1’s heels with a pillow for support.” LPA spoke with Health Service Director if facility has a log that tracks how often a resident is turned. The facility currently does have a log to track frequency of turning of residents.

On December 5, 2025, facility progress notes by LVN at 8:04pm document, “Pt noted to have unstageable wound on Left heel.” Care staff continue to observe the unstageable pressure injury in the progress notes and applied foam dressing and wound care. On January 16, 2025 Home Health delivered heel protectors to apply in heels daily.