complaint·October 6, 2025

It was alleged that the facility retaliated against R1 by adding additional unnecessary and non-medical care for R1 which was duplicative of the facility’s staff and charged R1’s responsible party without approval. Per R1’s family, on August 4, 2025, R1 had surgery to replace a foley catheter with a suprapubic catheter. R1’s Progress Notes indicate R1 returned to the facility the same day as the surgery and AD stated that after R1’s return, the facility monitored R1 and had the facility’s nurse change R1’s bandages as a temporary measure until home health was set up, but that it is the facility’s policy that home health needs to oversee catheters and wounds. R1’s Admission Agreement corroborates that the facility does not provide skilled nursing care. Per R1’s Medical Records dated August 4, 2025, R1 needed daily cleaning of the catheter site and replacement of bandages. Per R1’s family, on August 8, 2025, a meeting was held including R1’s family, AD, and facility staff and during this meeting the facility’s medical director advised that it was their opinion that R1 needed a higher level of care and should be in a skilled nursing facility. R1’s Medical Records dated August 8, 2025, indicate that a hospital recommended cleaning the skin and replacing the dressing around the catheter every day and as needed to help prevent infection. Per R1’s family, in order to meet R1’s needs, AD insisted that R1’s family set up home health to address the bandage changes. AD stated there were almost daily conversations with R1’s family regarding the fact that the facility could not meet R1’s needs of daily showers and bandage changes. Per AD, on August 13, 2025, the facility’s medical director reviewed R1’s records and determined R1 needs a higher level of care and the facility issued the 30-Day Eviction Notice dated August 14, 2025, on the basis that R1 needed a higher level of care. The facility’s medical director’s letter dated August 13, 2025, indicates that a transition to a higher level of care is medically necessary for R1, but does not indicate why. Per AD, this decision was made because the facility is not able to meet R1’s needs per their doctor’s order of daily showers and daily bandage changes. Per R1’s Medical Records dated August 19, 2025, R1 was approved to receive five home health visits for period of August 17, 2025, to November 15, 2025, to address R1’s catheter and R1’s Home Health Medical Records document that R1 was seen around twice a week by home health nurses for assistance with their suprapubic catheter starting on August 20, 2025. Per AD and R1’s family, prior to R1 receiving home health, the facility’s nurses changed R1’s bandages on a temporary basis. Per an email dated August 22, 2025, the 30-Day Eviction Notice dated August 14, 2025, was rescinded and a 24-hour private one-on-one caregiver was required at R1’s expense based on the facility’s medical director’s determination that this additional care is required to meet R1’s health and safety needs. However, neither this communication, nor the facility’s medical director’s letter dated August 13, 2025, indicate what those health and safety needs are. When asked why one-on-one supervision was required when R1’s only issue was wound care, which could not be met with one-on-one supervision, AD explained that, per facility policy, when a higher level of care is recommended, the facility institutes one-on-one supervision until the resident can be relocated to a higher level of care and in this case R1 had been observed by their family picking at the catheter site and due to R1’s cognitive issues a one-on-one caregiver would address this issue while educating the resident could not. R1’s Admission Agreement corroborates that the facility’s policy is to institute temporary one-on-one supervision at the resident’s expense when it has been determined that a resident needs a higher level of care and R1’s Progress Notes document that on August 8, 2025, R1’s family advised the facility that R1 had pain on their abdomen and was observed “picking” at the incision site. In light of the facility’s policy to initiate one-on-one supervision when a higher level of care is required, and the fact that R1’s approved home health visits, which had recently begun, could not even meet one-third of R1’s dressing change requirements, initiating one-on-one supervision was a reasonable measure to try to bridge the gap in care as the facility and R1’s family worked to find a solution. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. It was alleged that on August 8, 2025, R1 was observed to have a blood-stained catheter bandage, but that staff did not notice the stain or report it to R1’s doctor or responsible party, R1 was taken to the hospital, the hospital determined no additional treatment and R1 was able to return to the facility with no special care or changes in medication required. Per R1’s family, on August 4, 2025, R1 had surgery to replace a foley catheter with a suprapubic catheter. R1’s family stated that on August 8, 2025, R1 was observed with a blood-stained catheter bandage, which was not noticed or reported by staff. When interviewed, AD stated that the blood observed was only a small amount and was to be expected after surgery, paramedics arrived and agreed with AD’s assessment, but R1’s family insisted on taking R1 to the ER and R1 returned a few hours later. However, R1’s family stated it was actually AD who thought the blood was a major issue and wanted to send R1 to the hospital, R1’s family did not have concerns about the blood stain, and R1 returned from the hospital with no concerns or changes of condition noted by the doctor. R1’s Medical Records dated August 8, 2025, corroborate that R1 was seen at the ER, no treatment was needed, and there was no change in condition. No information was obtained corroborating that R1 had a change of condition or that the blood stain noted on R1’s bandages was unexpected after R1’s surgery. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.