Follow-up·December 18, 2025

On 12/18/25, Licensing Program Analysts (LPAs) Perchuhi Milena Khurshudyan and Tihesha Smith, conducted an unannounced Case Management visit to this facility. Upon arrival LPAs met with Shakila Ardakani Administrator and explained that the reason for this visit is to continue an investigation of the case management visit initiated on 12/08/2025. The purpose of today’s visit is to address issues and concerns regarding admission, readmission, and retention of resident #1 (R1) to the facility. On 10/17/25, LPA Khurshudyan received an Incident Report (IR) regarding R1, who developed wound on the right toe and per home health nurse evaluation R1 required antibiotic. On 10/23/25, LPA received another Incident Report regarding R1 being transferred to hospital due to wound infection on the toe. Prior to this visit LPAs Smith and Khurshudyan reviewed all available documents pertaining to R1’s health conditions. Upon further review of available medical records, including but not limited to Home Health, records, wound evaluate R1’s health condition, care plan, and the facility’s improper assessment practices related to R1’s return from the hospital. During this visit at approximately 1:20pm, LPAs conducted a brief physical plant tour to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit. Between 10:45am to 12:00pm, LPAs spoke with facility Administrator and reviewed additional medical records. Continue on LIC809-C Overall investigation revealed that on or before 10/17/25, R1 developed pressure injury(s) on their right toe and other pressure points including buttock. R1 was receiving home health care assistance. However, the wound(s) was not healing, and wound care specialist was contacted to attend R1 for further assistance. Between 10/17/25 and 10/23/25, the condition of the pressure injury(s) worsened and R1 was sent to the hospital. At the time of admission to the hospital, R1 was diagnosed with multiple unspecified pressure injuries and Sepsis. Hospital records state that resident was recommended to continue medical care in skilled nursing facility. However, per R1’s family request and refusal to transfer R1 to skilled nursing facility (SNF), R1 was readmitted back to the facility. R1 was discharged back to the facility with PICC/IV line for continuation of care. The hospital discharge records did not provide any information to verify that R1’s Sepsis was colonized, and the pressure injuries were healing. Overall investigation revealed that while in the facility R1 developed prohibited health condition, was hospitalized and later on 10/28/25 was readmitted to the facility without proper discharge record identifying the status of the infection and pressure injuries. Based on inspection, observation and record review the following citation was issued and recorded on LIC809D. An immediate $500.00 Civil Penalty will be issued for retention and readmission of the residents with prohibited health condition. Deficiency issued during today’s visit, check LIC809D pages. Exit interview conducted, copy of this report signed and delivered.