Interviews conducted with Executive Director (ED) indicated that Resident R1 had experienced issues with their catheter since January 2026. Staff have continuously worked with home health, hospice and R1’s physician to help decrease discomfort/pain that R1 had been experiencing since receiving the catheter. During the most recent event, staff noticed that R1 had more discomfort than usual and had a slight red color to the urine in the catheter bag. Staff reached out the R1’s power of attorney (POA) for next steps/transfer to hospital. R1’s POA requested that R1 not be sent to the hospital and have R1’s urine tested as an outpatient test. Staff reached out to R1’s physician requesting a test to which they declined and told staff that R1 needed to go to the hospital. Staff attempted to explain that it was the request of the POA to not have R1 sent out to the hospital and instead perform a urine test.

Documents reviewed indicated that facility staff had sent requests to R1’s physician indicating that R1 was having discomfort with the catheter. Physician responses were documented indicating prescribing of new medications to assist. Daily progress notes indicated that staff were watching R1’s urine output closely and were checking for any signs of infection while also reporting to home health services each day. Staff continued reports to home health, POA and physician’s office until urinalysis order was received on 01/30/2026. Facility staff followed instructions and continued to monitor.

Based on records reviewed and interviews, LPA finds the above allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Executive Director. Copy of report was given to facility.