Complaint·February 17, 2026

The investigation revealed the following: #1- Allegation: Staff are not adequately addressing the catheter needs of the residents. Interviews with Residents (R1–R5) were asked whether staff address their catheter needs and 1 out of 5 residents, stated that their catheter needs are being met by staff, who check on them every two hours or as needed. R1 informed (LPA) that staff are not permitted to assist with catheter care, but they do ensure that incontinence needs are met daily. R1 also reported that a hospice nurse visits the facility at least once a week to assist with catheter care. The remaining four residents (R2–R5) stated that they do not require catheter care. Interviews with Staff members (S1–S5) were asked if staff are addressing the catheter needs of the residents and 5 out of 5 staff members confirmed that catheter care is provided only by a licensed professional. Staff are permitted to empty residents’ urinal bags but not perform catheter care. Staff also reported that AAA Hospice Care & Nursing Inc. is the agency providing catheter care to residents once a week, with additional visits pending approval. #2 Allegation: Staff are not addressing the residents’ change in condition with an proper wound care plan . Interviews with Residents (R1–R5) were asked if staff are addressing changes in residents’ condition with a proper wound care plan and 1 out of 5 residents stated staff have been addressing their wound care needs by notifying the hospice agency /medical professional and visits are conducted once a week by a hospice agency. The remaining four residents (R2–R5) stated that they do not require wound care. Interviews with Staff (S1–S5) were asked if staff are addressing the residents change in condition with proper wound care plan and 5 out of 5 staff members stated that residents requiring wound care would receive services from a hospice agency/or medical professional. Staff also reported that they are not permitted to provide wound care, but they may perform bandage changes as needed. Based on staff observations, if additional care is required, the hospice agency is contacted immediately for further action. LPA reviewed the guest sign in sheet from 1/31/2026 through 2/17/2026 that reflects visits were made from the hospice nurses along with AAA Hospice Care & Nursing Inc. Flow Sheet dated for services rendered on 2/10/2026, 2/17/2026 for additional care and route sheets dated for 2/6, 2/7,2/10.2/12 and 2/14, 2026. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Mona Alcaraz Administrator at conclusion of the visit with appeal rights.