Complaint·October 4, 2024

On 10/04/2024 Licensing Program Analyst (LPA) M Vega arrived unannounced to deliver findings on the above allegations. LPA met with Sarah Dennis - Executive Director and Samantha Keith - Director of Resident Services, stated the purpose of the visit. Allegation: Staff do not ensure resident’s catheter is properly maintained. LPA conducted interview with R1 observed R1 ambulating and with no hose that would pose fall risk. Reviewed records for R1: Based on R1 facility notes, the monitoring of catheter is recorded. R1 Service Plan also indicates that, R1 has been on home health since admission. Although these allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. A copy of the report was provided to the licensee, No deficiencies issued, exit interview conducted.