Complaint Investigation Report

Per interview with Health and Wellness Director (HWD), facility does not track or have records of resident pull cord logs in Extended Care. HWD explained that pendant logs were only for Assisted Living residents.

Interview with Resident Care Manager stated that there is an expectation that pendants are responded to by facility staff within 5 minutes.

Review of R1’s care plan dated 08/28/2024 stated that they need assistance with their ADLs. Per R1’s care plan, they needed assistance with ambulation, transfers, bathing, incontinence, and dressing/grooming but did not indicate if any of these care needs required two staff members for assistance.

Review of R1’s pendant call records for November 2025, December 2025, and January 2026 showed that there were 100 entries with a wait response time of over 5 minutes. 37 out of 100 entries had a wait time of between 10 minutes and 27 minutes. 8 of 100 entries had a wait time of over 30 minutes with wait times recorded between 39 minutes and 96 minutes. These wait times occurred on the following dates: 11/08/2025, 11/19/2025, 11/24/2025, 12/05/2025, 12/12/2025, and 12/22/2025. Review of facility time sheets and staff schedules for these identified dates showed that facility had appropriate staffing.

Based on record review, observations, and interviews, this allegation is Unsubstantiated .

There is an allegation of "Staff mismanaged resident's medications." - Complaint alleged that facility did not have R1’s nebulizer or albuterol. Per complaint, R1’s albuterol was unavailable and therefore facility staff were “borrowing” the medication from another resident. Complaint was unable to provide additional information such as which resident the facility staff was borrowing albuterol from or when the albuterol was borrowed. Complainant stated that R1 received physician orders for the nebulizer equipment and albuterol medication on 01/07/2026 and 01/20/2026. Complaint stated that R1 did not have albuterol or their nebulizer on 02/04/2026, but did have their nebulizer available on 02/11/2026. Complainant further alleged the following: R1 had a rectal suppository medication for hemorrhoids and it was not available, facility was not following R1’s torsemide medication order stating that the facility was to check R1’s blood pressure before administering the medication, and that facility removed R1’s half bed rails even though R1 had a physician's order for it. Per Complainant, R1 received an order for half bed rails in May 2025 but the bed rails were removed in February 2026 when R1 moved to the facility’s Extended Care area. Complainant stated that R1 received a new order for half bed rails on 01/07/2026.

Albuterol and Nebulizer : Review of R1’s progress notes for 01/07/2026 stated that R1’s physician would order nebulizer and albuterol treatments. Review of R1’s file showed an order dated 01/07/2026 for two medications: Turmeric and Albuterol. Continued on LIC9099C