Facility Evaluation Report

On 10/26/2023, Licensing Program Analyst, Kimberly Viarella made an unannounced case management visit to this facility regarding an incident report that was submitted on: 10/01/23. LPA identified herself, the purpose of the visit and asked to speak with the Designated Facility Administrator. LPA met with Ann Marie Kneeland and a brief interview followed.

LPA was told that resident (R1) had a cast removed on 09/20/23 and that on 09/25/23 mother and staff observed swelling in R1's right foot/leg. The Administrator stated that the Doctor was notified by email and an appointment was made for 09/29/23 at 9:40 AM. On 09/26/23 PT Home Health Nurse, (N1) observed a bleeding wound on the back of R1's right heel. Administrator was told that another nurse would be out to evaluate the wound. On 09/28/23, another Nurse, (N2) came out and informed the Administrator that the wound was a stage 4 pressure sore. N2 instructed the Administrator to go to the scheduled Ortho appointment and that another nurse would be out to further evaluate R1's wound. On 09/29/23, Kaiser transport was late and the Administrator and R1 arrived 20 minutes late. They were told they would need to reschedule, and they returned back to the care home.

The Administrator reported that a third nurse (N3) arrived at the care home that day and measured the wound. It was 2.5 X 2 cm and N3 confirmed it was a stage 4 pressure sore. N3 informed the Administrator that R1 should be taken to the ER for Skilled Nursing Facility transfer because the care home was not licensed to take care of the wound and the Home Health Agency was not able to provide services on a daily basis.

R1 was taken to Kaiser ER by the responsible party but no beds were available. R1 was discharged into the responsible party's care until a bed became available at a Skilled Nursing Facility, or until hours for home care with responsible party could be acquired.