Complaint·October 14, 2025

9099C-1.. Resident (R1’s) Physician’s Report notes a primary diagnosis of Urinary Retention and a foley catheter is needed to assist. (R1) also needs assistance with transfers and dressing/grooming and is able to communicate and follow directions but is not able to leave the facility unassisted. Allegation: Staff did not allow resident to use the phone. The allegation state staff did not allow resident (R1) to use the phone to call out. The administrator stated that (R1) "was using the land line a lot" and they did not have a personal cell phone and asserted "other family members complained of the phone being busy and it not being answered", and it was due to (R1) being on the phone so much. The administrator added that during the day, (R1) was on the phone 1.5 hours sometimes and she "told (R1) they cannot be on the phone that long". The administrator stated (R1) was calling Canada and she told them "don't make too many out of state calls". The administrator confirmed the facility phone is a cordless land line, and (R1) would take the call to their room and was unsure if (R1) was making outgoing or receiving incoming calls. Four (4) residents stated they each use their personal cell phone and do not use the facility land line. (R1s) family member stated he is "not aware" of (R1) not being able to make outgoing calls and stated he called (R1) "numerous times and I was always able to talk to (R1)". Based on information obtained , LPA finds this allegation to be UNSUBSTANTIATED -meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Allegation: Staff did not follow physician’s orders. The allegation states staff would not give (R1) their psych meds or the Flomax for urinary retention; staff stole (R1’s) catheter kits to empty their urine, claiming the kits were for someone else at the facility. The administrator indicated (R1) did not have a catheter, but said they needed one due to having urinary retention. The administrator indicated she is not sure if (R1) moved in with a catheter as they "were using the commode". *cont on 9099C-2.. 9099C-2.. The administrator confirmed that (R1) "had a catheter kit" and "it did not disappear as no one else used a catheter". The administrator was unsure who gave the catheter kit to (R1). The administrator confirmed (R1) was administered medications as ordered and the facility uses a MAR, commenting that (R1) wanted to keep the meds in their room, but she told them they have to be centrally stored. Four (4) residents were asked if the facility administers medications as ordered. One resident said they don’t take any medications, two residents stated staff gives them medications, and a third resident was unsure if staff give them medication due to having a diagnosis of Dementia. (R1s) family member stated "no, not that I'm aware of" when asked if the facility was not giving medications. Hospital documentation shows (R1) went to the ER on 11/11/2024 and was given a diagnosis of Urinary Retention and was requested to schedule an appointment within (3) days with their primary care provider. (R1) moved to a related to a related facility on 11/15/2024. Electronic documentation show that all medications were administered as prescribed from 11/6/24 through 11/13/24. There is no note about (R1) having a catheter on the documentation. Based on information obtained , LPA finds this allegation to be UNSUBSTANTIATED -meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.