Complaint Investigation Report

The facility did not have a doctor's order for a gait belt for R1. LPA interviewed witnesses 1 & 2 (W1)(W2) which revealed while at the facility visiting R1, R1 raised up R1's arms and witnesses noticed a gait belt wrapped around R1's waist and tied to the back of the reclining chair R1 was sitting in. W2 stated they had never been told about a change in condition or the use of a gait belt for R1. Several texts messages were sent back and fourth between Administrator and R1's family regarding the incident. Based on the evidence this allegation is Substantiated at this time.

On the allegation: Licensee does not ensure enough staffing to meet the needs of residents. LPA interviewed Licensee/Administrator regarding the staffing needed for R1. R1 had a recent change in condition and sun downing was becoming an issue for R1. The change in condition was reported to R1's physician and Administrator is getting an up to date LIC 602A physicians report for the change, and will update the appraisal needs and services plan accordingly. Administrator stated R1 does need additional staffing during sun downing from 3pm-7pm or 4pm-8pm. Administrator plans to do a two day rate increase for the change in condition and to provide a staffing 1 on 1 to R1 during sun dowing to keep R1 safe. Administrator said the facility has hired 3 new staff in February 2025 but all 3 staff are no longer working, the administrator is currently hiring for caregivers and hired 2 new caregivers yesterday, once trained the staff will be added to the schedules. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator/Licensee.