Complaint·May 18, 2026

Coordinator and R1’s responsible party that the Facility’s care team would need to evaluate R1 at the hospital prior to R1’s discharge back to the facility in order to assess R1 and ensure that the facility staff could provide the necessary support to meet R1’s needs. On 12/31/2024, interviews conducted revealed the facility care staff consisting of the Clinical Case Manager, the facility LVN, and the facility Program Manager evaluated R1 at the hospital where R1 was observed to not open their eyes, did not acknowledge verbal communication or respond to being touched. Interviews conducted revealed at the time of the assessment, R1 was sleeping, laying on their back with R1’s legs contracted almost reaching their chest, and R1’s arms were also laying and contracted against R1’s chest. Prior to the facility’s assessment, interviews conducted revealed R1’s responsible party stated R1 was able to self-feed and had been evaluated for adaptive equipment to assist R1 feeding themselves and was able to conduct other daily living needs. At the time of the assessment, interviews conducted revealed R1 was unable to feed themselves, R1 had to be fed, and the hospital nurse assisting R1 stated R1’s feeding could last anywhere from 45 minutes to 1½ hours or more depending on R1’s ability to respond. Interviews conducted further revealed during the assessment, R1 was observed to have open wounds to their toes and ankle and a pressure ulcer on the buttocks; facility Clinical Case Manager requested a copy of R1’s Physical Therapy/Occupational Therapy and the Doctor’s recommendations but the hospital staff stated they did not have it on hand and would send the information to the facility Clinical Case Manager and the Program Manager. Interviews conducted revealed when the Facility Clinical Case Manager observed R1, R1 was unable to self-administer their medications and observed the hospital nurse administer R1’s medication to R1 on a spoon with either yogurt or apple sauce by placing the spoon in R1’s mouth. Interviews conducted further revealed Facility Case Manager inquired about a quadriplegic wheelchair for R1, the hospital case worker informed the facility Clinical Case Manager that R1 was completely “bed-bound”, and no report had been made to initiate the use of a quadriplegic wheelchair. Records reviewed and interviews conducted revealed prior to hospital discharge, R1’s care needs had significantly changed and new diagnoses were identified including dementia, peripheral arterial disease, and mild hyperkalemia. At the time R1 was to be discharged from the hospital, R1’s responsible party reported to facility staff that R1 was able to self-feed, self-administer medications, and R1 had been evaluated for adaptive equipment to assist R1 with R1’s Assisted Daily Living (ADLs) needs. Interviews conducted and records reviewed revealed the facility care team informed R1’s responsible party that the facility care team could not give an immediate response on whether or not the facility could accept R1 back into the facility until the documentation was received to provide to the facility's Utilization Review Team for determination of whether R1’s needs could be met. Records reviewed and interviews conducted, revealed on 1/3/2025 Facility Please continue to 9099-C, Pg 2. Program Manager sent an email to R1’s TCRC Service Coordinator with a CC to R1’s responsible party as well as other Facility Care Team members with an update that R1’s care needs had significantly changed and R1 needed a higher level of care above what their facility can provide, such as a skilled nursing facility (SNF). The email further stated if R1’s condition improved, R1 could be re-evaluated for potentially returning to the facility. Record review revealed TCRC Service Coordinator was asked if TCRC was willing to hold the bed for R1 and would TCRC fund R1’s position until R1 was re-assessed and determined to be able to return to the facility. Records reviewed revealed TCRC’s response was directed to R1’s responsible party requesting a decision on whether they wanted to keep R1’s bed open and requested from the facility Program Manager how long the bed could be kept available. Record review revealed TCRC communicated to facility Program Manager stating R1’s responsible party replied stating they would like to release the room and R1’s responsible party will start the move-out process. Record review revealed on 1/7/2025, TCRC confirmed the release date of R1’s bed and was to be backdated to 1/3/2025. Interviews conducted revealed on 1/7/2025 R1’s responsible party came to the facility and began removing R1’s personal belongings and retrieved the remaining belongings on 1/8/2025. Based on records reviewed and interviews conducted, the allegation that staff illegally evicted resident in care is Unsubstantiated at this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.