Incident investigation·March 11, 2025

On March 11, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding an incident when the resident (R1) presented with a sudden change of condition and the nurse assessed and observed that the resident had removed his supra pubic catheter. Upon arrival, the LPA was greeted by the Executive Director (ED), Li Li. The LPA disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 183. Based on the review of the facility file records, the facility did not have an exception granted in place for R1’s suprapubic catheter, a restricted health condition. LPA and ED had a phone conversation with Mariam Perez, Vice President of Clinical Services at Wellquest Living (VP). VP stated they had a phone call with CDSS on March 7, 2025 and were told there was no need to file an exception request for catheter. ED stated they had the requested documents ready to submit for an catheter exception request, if there was a need to be. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was left with the Executive Director, Li Li, whose signature on this form confirms receipt of the report.