Facility Evaluation Report

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit.

LPA Moleski reviewed five resident files (R1-R5) and five staff files (S1-S5).

LPA Moleski reviewed R1's file. R1's LIC 602 was dated 6/21/25. R1's move-in date was recorded as 7/28/25. R1's LIC 602 indicated that R1 had a pressure injury, but it was not staged. R1's LIC 602 indicated that R1 did not have home health services. In an interview, the facility's health services director (S6) said that they were not aware R1 had a pressure injury upon admission. An assessment for R1 dated 7/27/25 indicated that R1 did not have any wounds or bedsores. Dial said he received R1's LIC 602 from R1's previous placement on 7/25/25. LPA Moleski reviewed ongoing notes for R1. An "open area" was identified on R1's heel on 7/29/25, according to a note written on that same date. On 8/3/25, a "worsening condition of wound on left heel" was noted. The "top skin layer came off," and was "oozing and bleeding," according to the note. An incident report from 8/3/25 indicated that R1 was sent to the hospital, and S6 "started the process of obtaining a referral for home health" on that date. S6 said that R1 received no wound care at the facility prior to 8/7/25, when home health personnel visited for the first time. S6 said that they would have been able to secure a referral for home health prior to R1's admission if they were aware that R1 had a wound.