Complaint·June 17, 2025

9099C-1.. Resident's Pre-Appraisal notes (R1) needs maximum assistance with mobility/transfers, bathing, toileting, can display argumentative/aggressive behaviors, needs occasional redirecting with taking medications and has a Stage 1/2 pressure sore. (R1's) physician's report (dated 5/13/25) indicates resident has a diagnosis of Mild Cognitive Impairment (MCI), Hypertension, Diabetes Melitis 2, anxiety and depression, history of skin breakdown- bed sore; intermittent confusion and agitation, recurrent UTI's and requires a low salt/carbohydrate diet. The Assistant Administrator stated on 5/22/25 that (R1) has "MCI" and "refused care" from staff after moving in on Friday night, May 16, 2025. The Assistant Administrator explained that (R1) moved in with an "external catheter" which was "not there when she was assessed", commenting that the hospital where (R1) was admitted from always discharges residents with multiple documents, and there were no orders for the catheter or any notes that (R1) had a history of resisting care". The Assistant Administrator explained how (R1's) catheter was removed Sunday morning following its discovery by a home health nurse. LPA was provided with text message documentation between the Assistant Administrator and the placement agency discussing how (R1) refused care at the hospital too, prior to moving in, and how the placement agency was "completely unaware of the catheter due to no notes" from the hospital. The Assistant administrator explained that (R1) "has refused care 4-5 times but has not refused care as of Sunday (May 18, 2025). The manager stated that (R1) moved in Friday night and by Saturday, late morning, got changed and had (2) soiled diapers and was starting to accept care but then refused care for the NOC shift (11 pm- 7 am). LPA reviewed documentation made by staff, to show incontinent checks and/or diaper changes made, every (2) hours, during the NOC shift, from May 18, 2025 through May 23, 2025. The Administrator stated she visited Saturday afternoon, May 17, 2025, and assured (R1) facility staff would be providing good care due to their backgrounds and experience. The Administrator explained to LPA that upon discharge, the hospital inadvertently left the PicWick catheter taped on (R1's) private parts, causing all urine to be "sucked up" and resident to appeal dry in the diaper. The Administrator stated she received a call on Sunday, May 18, (11:00 am) , from staff, (S1), to communicate that a home health nurse pointed out that a catheter was left in place. The Administrator then contacted the home health nurse to explain the facility does not use this type of catheter, due to the cost, and the facility is non-medical. The Administrator commented that (S1) should have called her earlier when she noticed the catheter, even though she wasn't sure what it was. *cont on 9099C-2.. 9099C-2.. The Administrator stated on 5/22/25 that Chux pads, both disposable and cloth, have been used for (R1) and was adamant that "the sheets were never wet", commenting (R1) received more bed baths than usual" due to the barrier creme being used. The Administrator stated she was informed via text message on May 16, 2025 (4:26 pm) that (R1) was "refusing care" starting on the first day and provided LPA with a copy of this text. One text message (sent at 4:59 pm) notes staff checked on (R1) on Saturday, May 17 and again Sunday morning, May 18, and (R1) was dry and with no bowel movement explaining (R1) "occasionally declines assistance". The Assistant Administrator commented on May 22, 2025, (R1) is doing wonderfully now- their son, visits daily", explaining "if (R1) refuses medications for diabetes or incontinent care, we send them back to the Emergency Room within 24 hours". LPA was not able to contact (R1's) responsible person to confirm any information from May 18, 2025. LPA observed the facility to be clean, in good repair and odor-free on 5/22/25 and on 6/17/25. Additionally, food and incontinent supplies were checked and found to be sufficient on both dates. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- A finding that a complaint allegation 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. Exit interview. Copy of report provided.