Complaint·April 22, 2026

(Cont. from LIC 9099) Regarding the allegation that the licensee retained a resident(R1) with a prohibited condition, interviews revealed that R1 arrived unexpectedly during the evening of 07/15/2024 with multiple wounds, and facility staff immediately contacted the on-call nurse and the discharging social worker to clarify expectations for care. Interviews with R1's outside care team stated that the hospital discharged R1 prematurely, due to hospital practices to discharge within a three-day window or as soon as medically stable, even when a resident requires a higher level of care. Interviews with R1's care team further revealed that the hospital recommended that R1 go back to assisted living under hospice services or skilled nursing facility, however R1's responsible parties declined and requested that the resident return to the facility. Interviews revealed that upon the resident’s arrival, facility staff immediately contacted the care team and sought guidance. The resident was subsequently enrolled in hospice, and skilled wound care was assigned to outside licensed providers. Records revealed that R1 was discharged from the hospital on 07/15/2024 and hospice did not begin providing oversight until the evening of 07/17/2024. Records review of email correspondence from the facility administrator on the evening of 07/15/2024 showed immediate communication with R1's care team, documenting R1’s arrival condition, the discovery of an unstageable wound, and coordination to determine how often the care team or home-health nurses could visit to address wound care. Additional email correspondence from the next morning, 07/16/2024, summarized the Administrator’s call with the care team, clarifying that the facility had not been informed of the discharge, had refused to accept the resident until receiving a revised 602, and reiterated that the facility could not provide skilled wound care and would follow R1's care team and hospice directives. The Administrator emphasized collaboration with the care team and expressed full support for placement in a skilled nursing facility if the care team determined it was appropriate. Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. An exit interview was conducted with Administrator Nikki Mundhada and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided via email.