Complaint Investigation Report

The allegation of “Residents who are bedridden are being retained in a room without bedridden fire clearance” alleges that the facility is retaining two (2) bedridden individuals in a non-bedridden approved room in violation of their fire clearance. LPA identified resident #1 (R1), and resident #2 (R2) as the subjects of the complaint. LPA conducted a physical plant tour and observed R1 and R2’s room. R2 was not present at the facility during the inspection. During the interview with S1 they confirmed that they do assist R1 and R2 with repositioning in bed. S1 stated that they assist R1 and R2 approximately every two (2) hours. S1 stated that R2 was able to reposition without assistance until approximately two (2) to three (3) weeks ago. LPA interviewed R1 who confirmed that they require assistance with repositioning in bed. During the interview R1 demonstrated the inability to reposition without assistance. Additionally, R1 stated that they and R2 are roommates. R1 confirmed that R2 requires and is being provided with assistance in repositioning in bed. LPA reviewed R1 and R2’s resident files. R1’s medical assessment dated 10/15/2024 identifies them as “non-ambulatory” and R2’s medical assessment dated 07/09/2025 identifies them as “non-ambulatory”. LPA interviewed Witness #1 (W1) who confirmed that their criteria for determining if a resident is “Non-Ambulatory” Vs. “Bedridden” includes determining the resident’s ability to reposition themselves in bed without assistance. W1 confirmed that R1 is no longer a client of their office. LPA interviewed the facility Administrator who confirmed that R1 is “Mostly” bedridden and receives assistance from staff with repositioning. The Administrator stated that R2 began needing assistance with repositioning around 07/10/2025 before their hospitalization on 07/12/2025. LPA reviewed the facility’s fire clearance and observed that the facility is cleared to retain one (1) bedridden resident in bedroom #3 only. LPA observed both R1 and R2 to reside in bedroom #1 which is only cleared for non-ambulatory residents. LPA informed the Administrator that retaining bedridden residents in a room which is designated as non-ambulatory is a violation of their fire clearance and an immediate civil penalty in the amount of $500 is being assessed on today’s date (07/21/2025). LPA informed the Administrator that per their approved fire clearance they may only retain one (1) bedridden resident and failure to relocate the bedridden resident to the bedridden approved room may result in the issuance of a 100$/day civil penalty. Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Residents who are bedridden are being retained in a room without bedridden fire clearance.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiency and civil penalty were cited (refer to LIC 9099D). This report was read to the Administrator via telephone call. A copy of the report was printed, appeal rights were provided, and exit interview was conducted.