Complaint Investigation Report

It was further alleged that staff are in a room at night, and if residents need something they have to knock on a staff door for assistance. LPA found that, through interviews with residents and staff that night shift staff sleep during the night, and do not remain awake to assist and direct residents. The facility was found to have dementia residents in care via R2's Physician's Report, and that comes with a requirement that there is awake staff. Thus, this allegation was SUBSTANTIATED.

It was then alleged that staff tie a resident to a chair at night to prevent them from wandering into other resident's rooms. Through interviews with staff, LPA found that R2 is restrained to a rocking chair in the living room with a sheet to prevent R2 from walking throughout the facility at night. Staff were found to sleep after R2 is asleep in their chair. Thus, this allegation was SUBSTANTIATED.

It was also alleged that there are three residents sharing the same room. Upon inspection, LPA observed three residents, Resident 4 (R4), Resident 5, (R5), and Resident 6 (R6) sharing the same bedroom. Thus, this allegation was SUBSTANTIATED.

The facility was issued 4 citations per Title 22. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC9099, LIC9099-C, LIC9099-D, LIC811, and Appeal Rights.