complaint·February 25, 2026

During the investigation the department interviewed 2 staff (S1-S2) and Administrator (ADM) On 07/07/25 Resident (R1) was receiving hospice services and had had an issue with his/her catheter. R1 was found by staff S1 nat 5:00pm with urine and blood on his/her bedding. Staff (S1) stated he/she called ADM to inform what was going on. ADM arrived shortly after and observed R1 in pain and grimacing and the resident had no urine output for about 8 hours. ADM, who is a Licensed Registered Nurse , stated that the caregiver had called the Hospice nurse and informed them what was going on and that the hospice nurse was on their way to the facility. ADM stated it had been almost an hour since the hospice nurse had been notified and that the resident had a distended abdomen and pain in which the ADM took it upon him/herself to remove the catheter placement and reinsert the suprapubic catheter. Witness (W1) arrived after ADM had changed the catheter and decided to call the ambulance. R1 was sent to the hospital where R1 was admitted with a chief complaint of blood in the urine. Based on R1s medical records during the hospital visit a Computed Tomography, (CT) scan was done and the results of (CT) indicated catheter was in good position and clinically draining well with no need for bladder irrigation. R1 condition was stable and returned to the facility the same day. On July 12. 2025 R1 passed away, based on record review R1s cause of death was not related his/her catheter care. The department has investigated the complaint allegations listed. Based on interviews and review of records, the department has found that the complaint allegation is unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with the Licensee and a signed copy of this report was provided During the investigation the department interviewed 2 staff (S1-S2) and Administrator. On 07/07/25 Resident (R1) was receiving hospice services and had had an issue with his/her catheter. R1 was found by staff S1 nat 5:00pm with urine and blood on his/her bedding. Staff (S1) stated he/she called ADM to inform what was going on. ADM arrived shortly after and observed R1 in pain and grimacing and the resident had no urine output for about 8 hours. ADM, who is a Licensed Registered Nurse , stated that the caregiver had called the Hospice nurse and informed them what was going on and that the hospice nurse was on their way to the facility. ADM stated it had been almost an hour since the hospice nurse had been notified and that the resident had a distended abdomen and was in pain in which the ADM took it upon him/herself to remove the catheter placement and reinsert the suprapubic catheter. ADM stated that staff had called hospice nurse and informed him/her of resident’s condition. ADM stated that anytime a resident is on hospice services the staff inform the hospice nurse before calling 911. ADM stated that when a resident moves into the facility the POA is notified regarding any resident health update or financial concern. ADM stated that POA stated to please contact Care Manager regarding any health concerns due to Care Manager being located closer to the facility. At the time of incident staff notified Care Manager of residents condition and was instructed to call Hospice Nurse. Based on interviews and record review the incident that occurred on July 7 2025, the facility followed hospice procedure and called hospice nurse of R1's catheter leaking blood and urine. ADM stated that the staff called Care Manager who arrived shortly after the catheter was reinserted. Based on interviews, records review and observations, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with the Licensee and a signed copy of this report was provided On 07/07/25 Resident (R1) was receiving hospice services and had had an issue with his/her catheter. R1 was found by staff S1 at 5:00pm with urine and blood on his/her bedding. Staff (S1) stated he/she called ADM to inform what was going on. ADM arrived shortly after and observed R1 in pain and grimacing and the resident had no urine output for about 8 hours. ADM, who is a Licensed Registered Nurse , stated that the caregiver had called the Hospice nurse and informed them what was going on and that the hospice nurse was on their way to the facility. ADM stated it had been almost an hour since the hospice nurse had been notified and that the resident had a distended abdomen and pain in which the ADM took it upon him/herself to remove the catheter placement and reinsert the suprapubic catheter. W2 stated that the resident moved into the facility on March 1, 2025 and had a catheter that was being cared for by home health. ADM provided a copy of R1s Hospice agreement dated April 7, 2025 stating that Hospice services would oversee changing the catheter once a month. ADM stated she was aware of the agreement. ADM felt that the resident was in pain and discomfort and felt it was necessary to change the catheter because of no urine output. ADM did not have a doctor’s written order stating he/she was authorized to change R1s catheter. R1 was under a Hospice service agreement that states Hospice services will be provided by a hospice nurse. Hospice nurse was notified by staff at the facility and did not arrive till shortly after R1s catheter was already changed by the ADM. R1s was sent to the hospital to check if the catheter was properly placed and there was no injury from the ADM changing the catheter. Documentation stated R1s catheter was properly placed and clinically draining well. Although ADM is a Licensed Registered Nurse he/she did not follow the signed Hospice Agreement dated February 25, 2026. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Citations noted today. Please see LIC9099-D. Exit interview was conducted with Xi-Ha Luo, ADM. A copy of the report and appeals rights were provided.