Complaint Investigation Report

three witnesses confirmed the allegation. One of three witnesses could not confirm, nor deny the allegation.

It was alleged that Staff are not responding to resident's call button in a timely manner. LPA obtained the June 2026 Device Activity Report for Resident #1 (R1)'s pendant calls. Per report, there were no pendant calls received on June 12, 2026. Eight of eight staff were interviewed and staff reported R1 has a difficult time pressing the pendant due to ongoing skin lesions. Staff stated there was one instance where it was reported to the facility that R1 could not reach the pendant; which was placed on a bedside table. Staff stated they had recently changed R1's shirt and had placed the pendant on the table. Staff then put the pendant on R1's neck. Eight of eight staff denied the allegation.

Staff stated on the evening of 6/12/2026 that a phone call was received stating R1 was requesting medications. Care staff stated they responded to the call within ten minutes and notified the Med Tech and the as needed pain medications were provided. Progress notes from 6/12/2026 stated R1 requested pain medication at 9:30pm and that it was administered and tolerated well and that staff were monitoring R1 frequently.

Four of eight residents interviewed denied the allegation that staff are not responding to resident's call button in a timely manner. One of eight residents confirmed the allegation. Three of eight residents could not confirm, nor deny the allegation since they do not use pendants. Two of three witnesses confirmed the allegation and one witness could not confirm, nor deny the allegation.

Based on LPA interviews, record review and observations, the allegations that Staff are not administering resident's medication in a timely manner and Staff are not responding to resident's call button in a timely manner are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director (ED) Susan Allen and a copy of this report and LIC 811 were provided to the facility.