Complaint·February 15, 2025

visit. On 12/20/23, R1 was admitted to the hospital for wound care. According to the administrator, Rima Agaronyan, R1 was admitted to the facility 11/10/23. The SNF never notified her of any wounds. Review of R1’s physician report and preplacement appraisal also do not indicate any wounds or skin break downs. After admission, on or around 11/10/23, while R1 was getting assistance with bathing, staff observed a wound. Home Health (HH) was notified on 11/11/23. The administrator was advised that a nurse will come out within 24 hours. When the HH Nurse came out to make an assessment, there was no indication by the nurse, at that time, of the wound being open. R1 was still sent to the hospital, but it was agreed that R1 can return to the facility as wound was not greater than stage 2. Review of the hospital records indicate the following: 11/10/23: R1 was discharged from Rehab to the board and care. 11/17/23: Home Health referral from primary care physician for physical therapy and wound care (nurse to apply cream to R1's wound). 12/05/23: R1 assessed to have stage 2 pressure ulcer. 12/06/23: R1's wound possibly progressed to unstageable. R1 was sent to Emergency Department (ED). 12/06/23: R1 sent to ED for evaluation. Chief Complaint- Pressure Ulcer Assessment. There was a Decubitus ulcer present, but no increased signs of warmth, signs of infection, discharge, significant tenderness or any indication for acute intervention. Case Manager met with the licensee and R1’s responsible person. They were all comfortable and agreed to have R1 going back to the facility. 12/20/23: HH nurse indicated wound not healing and has a lot of dead tissue. Referral to clinic. 12/20/23: There was another indication of wound progressing to possibly stage 3 and 4. Debrided to healthy bleeding tissue. R1 transported to the hospital. (Per hospital staff interview, nurse confirms R1 was sent back to the hospital on 12/20/23). Based on the information obtained, although there is record that R1 has a pressure injury, there is evidence that the licensee tended to, and monitored R1’s condition, until it progressed to a possible prohibited condition. There is also evidence that the administrator was in contact with HH regarding R1’s wound. Once R1’s wound did not show improvement, or had progressed, R1 was sent to the ED for immediate medical attention. Therefore, based on the information obtained, the above allegations are deemed Unsubstantiated at this time.