Complaint Investigation Report

R1, R4, and R6, conducted a medication review for four (4) residents, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Resident R5’s Physician Report, Physician Order, Needs and Service Plan, and eMAR for R1-R5 for July 2025.

The investigation revealed the following:

Allegation: Staff does not respond to residents call button in a timely manner

The allegation alleges that staff respond to residents call buttons within 30 to 60 minutes.

During the facility tour, LPA visited Residents R1-R5 in their rooms or in the facility. During each visit, the residents’ pendants were pressed upon meeting. The following times were the response times to each call: R1 (room 513) staff responded in 6 minutes, R2 (in bistro area) staff responded in 4 minutes, R3 (room 221) staff responded in 7 minutes, R4 (common area) staff responded in 6 minutes, and R5 (room 133-pulled cord) staff responded in 5 minutes.

LPA received and reviewed Pendant Logs for five (5) Residents for the month of June 2025. LPA observed three (3) out of five (5) residents’ calls for assistance were not answered in a timely manner. LPA observed the following for Resident R1, there were 21 times, in the month of June 2025, that took staff over 15 minutes to clear the call. For Resident R3, there were 21 times, in June 2025, that took staff over 15 minutes to clear the call. For Resident R4, there were 45 times, in June 2025, that took staff over 15 minutes to clear the call.

During interviews with Staff S1-S7, were asked how long it takes to respond to a resident’s pendant or cord pull, seven (7) out of seven (7) stated it should take 5 to 10 minutes to respond to residents’ calls for assistance.

During interviews with Residents R1-R8 , were asked if staff respond to the pendant and/or pull cords in a timely manner, four (4) out of eight (8) stated they have had to wait an extended period of time before staff came to provide assistance.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

Allegation: Staff did not administer medication to a resident.

The allegation alleges that a resident was not administered their medication.

During the facility visit, LPA audited the Centrally Stored Medication, Physician Orders, and eMAR, from July 1, 2025 to July 11, 2025, for Resident’s R1-R5. LPA observed five (5) out of five (5) residents medications were not consistent with properly documented records. The audit revealed Resident R1 had two extra pill in