complaint·January 8, 2026

Continued from LIC 9099 Investigation Findings: It was reported to the department that the facility is retaining a resident who is mentally incapable of caring for their catheter. LPA toured the facility and found only one resident with a catheter. Record review of R1 showed R1 requires assistance with all Activities of Daily Living (ADLs). LPA reviewed R1’s Care Plan that shows that Center for Elderly Independence Program of All-Inclusive Care for the Elderly (CEI PACE) providers are responsible for all medical care of the catheter via CEI Home Care Nurses, visits to the CEI Clinic, or Emergency Room (ER). The CEI nurse comes every six weeks to change out R1’s catheter. If CEI is unavailable, staff will take R1 to the emergency room if it needs to be replaced. LPA called CEI and spoke with W1, a register nurse, that confirmed W1 trained the facility staff in the care of R1’s catheter and is one of two nurses that will come out to the facility every six weeks to change out R1’s catheter. Staff in the facility only empty out the bag when it gets full. LPA obtained training records that show six staff members were trained by a registered nurse from CEI, W1, in how to handle and care for the catheter. Staff members are scheduled in a manner that ensures coverage by both the facility staff and CEI’s nurses for R1’s catheter. Based on the information obtained, observation and interviews, this allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.