Facility Evaluation Report

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation unrelated to Complaint Control No. 22-AS-20250919161621. LPA met with Administrator (AD) Peggy Ulland and explained the reason for today’s inspection.

During the course of the investigation, LPA inspected the facility, conducted interviews, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Home Health Plan of Care, Resident #2’s (R2) Medical Records, R2’s Hospice Order, and R2’s Facility Health Care Visit Reports.

Per the facility’s wellness director, R1 had a suprapubic catheter placed while they resided in the facility and R1’s family moved them out of the facility for a higher level of care approximately three weeks later. R1 had multiple falls which were not related to the care of the suprapubic catheter, caregivers emptied R1’s catheter bag, and R1 voluntarily moved out. The facility did not have R1’s home health records, did not communicate with R1’s doctor or home health regarding R1’s catheter care needs, and had no information on what R1’s catheter care needs were and whether they were met. LPA obtained R1’s Home Health Plan of Care from the family which documents R1’s catheter care needs, but the facility was unable to show that these needs were met at the facility before R1 moved out.

Per AD and the facility’s wellness director, R2, a current resident on hospice, also has a suprapubic catheter, but the facility does not have R2’s home health or hospice records. R2’s Medical Records and R2’s Hospice Order do not identify R2’s catheter care needs. R2’s Facility Health Care Visit Reports document that R2 received two and sometimes three visits a week from home health and later hospice, catheter care was provided during many of these visits, and no concerns were noted with the care R2 was receiving for their catheter. However, the facility was unable to provide information or documentation of what R2’s catheter care needs were or whether they were met.