Complaint·May 20, 2026

hospitalized on 11/21/2024. On 12/31/2024, R1 was re-assessed by facility’s Clinical Case Manager, LVN, and Program Manager. Following the assessment, 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, such as a skilled nursing facility (SNF), which is above what their facility can provide. 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 would continue to fund R1’s bed while R1 recovered and could be re-assessed for potential return to the facility. Interviews conducted revealed the facility did not issue a 30-day eviction notice to R1 and/or R1’s responsible party. Records reviewed revealed TCRC Service Coordinator and R1’s responsible party responded to facility staff stating they would like to release R1’s bed and the release date was backdated to 1/3/2025. Based on interviews conducted and records reviewed, the allegation that staff did not adhere to resident’s admission agreement is deemed Unsubstantiated at this time. On the allegation, Resident developed pressure injury while in care. It is has been alleged that R1 developed a Stage 3 wound to R1’s Right Leg Extremity (RLE) while residing in the facility. Records reviewed revealed hospital care management notes dated 12/11/2024 state R1 developed the wound while at the facility. R1 was admitted into the facility on 6/14/2023. Upon admission, R1 was assessed by the facility LVN at which time, an open wound was discovered, and the treatment team made the decision to send R1 out to be evaluated and to have the open wound staged. Records review revealed R1’s wounds and bruises of unknown origin were observed at the time of R1’s admission into the facility and subsequent reports were submitted to CCLD, TCRC, Long Term Care Ombudsman (LTCO) and local law enforcement as required. Over the duration of R1’s care while residing in the facility, there was a change in condition where R1’s health was declining, their abilities were declining, and R1 became less mobile, less responsive, and less interactive with others. As R1 began to decline and became less mobile, R1 was spending more time in bed and in a wheelchair and developed pressure ulcers. The facility submitted an exception request for a “Prohibited Health Condition” to Community Care Licensing Division (CCLD) and the exception request was granted on 6/23/2023. A second exception request for a prohibited health condition was requested and granted by CCLD on 12/4/2024 specifically noting “Stage 3 Pressure Injuries to the right ankle and toe”. Interviews conducted revealed R1’s Responsible Party was informed that R1 had developed a Stage 3 pressure ulcer and in order to allow R1 to remain residing in the facility, R1’s responsible party requested the second exception. Interviews conducted revealed R1’s responsible party was aware that the wound care must Please continue to 9099-C, Pg 3. come from the outside wound care agency and the facility staff are not allowed to provide such services. Prior to R1’s admission into the hospital on 11/21/2024, the wound care nurse attended to R1 twice each week and on the nurse’s regularly scheduled visit, the nurse noted on 11/20/2024 signs and symptoms of possible infection to R1’s RLE. At that time, the wound care nurse instructed the care team to send R1 out for care to the hospital if R1 developed a fever. Records review revealed upon R1’s admission into the hospital on 11/21/2024 and the hospital care management notes cited the wound on 12/11/2024 and during that time, R1 remained in the hospital. Interviews conducted revealed Program Director stated although R1 may have developed a pressure injury while in care, it is at no fault of the facility and it is noted that R1 has had a history of the wounds and the facility took all the appropriate and required measures to ensure R1’s proper care of wounds including but not limited to requesting two exceptions for Prohibited Health Conditions on two separate occasions and bringing in outside wound care specialists who provided the facility with guidance and instruction for R1’s care. Based on the interviews conducted and records reviewed, the allegation that Resident developed a pressure injury in care is deemed Unsubstantiated at this time. On the allegation, Staff altered resident records: It is alleged that facility staff did not follow proper procedures when documenting self-administration of R1’s Clonidine 0.3mg/24 hr patch. Responsible Party voiced concern that the Medication Administration Record (MAR) from 12/1/2024 through 12/31/2024 was documented as to R1 having been administered the medication on a daily basis. Record review and interviews conducted revealed R1 was out of the facility from 11/21/2024 through 12/31/2024. Interviews conducted revealed R1’s MAR for the month of December 2024 indicates “A” meaning R1 was “away” from the facility and the medications were not administered. Based on records reviewed and interviews conducted, the allegation that Staff altered resident’s records is deemed Unsubstantiated at this time. On the allegation, Staff mismanaged resident medication: It has been alleged that staff mismanaged R1’s Clonidine 0.3mg/24 hr patch. Responsible Party voiced concern that the Medication Administration Record (MAR) indicates the medication was administered from 12/1/2024 through 12/31/2024. Interviews conducted with Program Director indicated records were not mismanaged as R1 was in the hospital throughout the month of December 2024 and documentation does not indicate medications were administered. Further, Program Director stated the MAR record reveals “A” for “away” for all days in the month of December 2024 as a standard procedure to indicate medications have not been administered. Based on records reviewed and interviews conducted, the allegation that Staff mismanaged resident medications is deemed Unsubstantiated at this time. Please continue to 9099-C, Pg 4. On the allegation, Staff did not safeguard resident’s personal belongings: It has been alleged that facility staff failed to provide R1’s responsible party with R1’s personal belongings such as November 2024 Medication Administration Record (MAR), leftover Ensure Nutritional Supplement, and wound care products. Interviews conducted revealed R1's responsible party obtained all of R1's personal belongings including medications and Medication Administration Records for the entire time R1 resided in the facility. Interview conducted revealed all of the belongings requested were provided to R1's responsible party on or about 1/8/2025. Interview conducted with facility LVN revealed all Medication Administration Records were given to R1's responsibility party. Records reviewed and interviews conducted revealed November 2024 MAR was also sent via email from Records Tech to R1’s responsible party on 11/13/2025 at 2:59 pm. Interview conducted with Facility LVN revealed at the time of R1’s hospitalization on 11/21/2024, LVN informed R1’s responsible party that R1 had no remaining containers of Ensure Nutritional Supplement. Program Director stated the facility does not retain wound care supplies because they do not provide wound care services and the outside agencies are responsible for all wound care supplies. Based on interviews conducted and records reviewed, the allegation that Staff did not safeguard resident’s personal belongings is deemed Unsubstantiated at this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.