Complaint Investigation Report

Regarding the allegation, Licensee staff do not respond to residents calls for assistance timely. More specifically, reporting party (RP) reports concerns regarding delayed pendant response times for a Resident #1(R1), including instances where the resident reportedly waited extended periods for assistance with meals and personal care. The reporting party expressed concern that these delays may have impacted the resident’s comfort and well-being. As part of the investigation, the Department conducted a review of pendant call data for September and October 2025 and revealed the average response time across all calls was approximately 16.2 minutes. To further assess the concern, the Department also reviewed call response trends and conducted interviews with staff, other residents, and family members. Staff reported that pendant calls are monitored and responded to as promptly as possible, with prioritization based on resident needs and time of day. Interviews with other residents on the same floor revealed general satisfaction with response times, though some acknowledged occasional delays during peak hours, such as mornings, when multiple residents may require assistance simultaneously.

It was reported that due to staff neglect, Resident 1 (R1) sustained pressure injuries. More specially it was reported, R1 developed sores on the lower body after becoming bed-bound. A review of the physician’s report and updated care plan indicated R1 is not classified as bedridden however, they are enrolled in hospice care. As part of the investigation, the Department interviewed hospice staff and reviewed R1’s hospice care plan. Staff interviews and documentation confirmed that wound care was administered by trained personnel per physician orders and hospice protocols. During the Department’s interview, R1 expressed concern that staff were not trained to use the Hoyer lift. However, records and staff interviews confirmed that staff had received training on its use. No documentation supported the concern regarding lack of training. Additionally, records and staff interviews indicated R1 had declined assistance to get out of bed on multiple occasions since the fall on October 14. These refusals were documented in care notes and communicated to the care team. Observations, interviews, and records confirmed R1 is capable of repositioning in bed and does so with occasional staff assistance.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Associate Executive Director Aileen Spence, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.