Complaint Investigation Report

On the allegation: Staff leave residents unattended for extended periods of time. LPA De Leon reviewed call button logs for the 7 randomly chosen residents at the facility for a 7-day period from June 1, 2025-June 7, 2025, which revealed 3 out of 7 residents reviewed had call button logs over 15 minutes to a maximum of 96 minutes. One Resident had 9 calls over 15 minutes, 1 at 15 minutes, 2 at 16 minutes, 1 at 18 minutes, 1 at 20 minutes, 1 at 21 minutes, 1 at 22 minutes, 1 at 25 minutes and 1 at 48 minutes. The next resident had 1 call at 37 minutes, another Resident had 7 calls with 1 at 15 minutes, 1 at 16 minutes, 1 at 17 minutes, 1 at 19 minutes, 1 at 40 minutes, 1 at 50 minutes and 1 at 96 minutes. Staff interviews revealed call buttons are usually answered in under 10 minutes if the facility is fully staffed. Staff stated residents use the call buttons for non-emergent matters at times. LPA reviewed records and there is no way for staff to tell if the next call button press is non-emergent or an emergency matter unless staff go to the location and check on the resident. Staff interviews revealed the facility was short staffed for periods of time during 2024-2025 and during those times when the facility was short staffed it took longer to answer the calls while doing regular duties assigned with resident’s showers, dressing, transferring and assistance. Staff stated that when they are with a resident, they must finish taking care of the resident before they can move on to the next call or the next duty assigned. Based on the evidence this allegation is Substantiated at this time.

On the allegation: Staff do not respond to requests for assistance from residents. LPA De Leon reviewed call button logs for the 7 randomly chosen residents at the facility for a 7-day period from June 1, 2025-June 7, 2025, which revealed 3 out of 7 residents reviewed had call button logs over 15 minutes to a maximum of 96 minutes. One Resident had 9 calls over 15 minutes, 1 at 15 minutes, 2 at 16 minutes, 1 at 18 minutes, 1 at 20 minutes, 1 at 21 minutes, 1 at 22 minutes, 1 at 25 minutes and 1 at 48 minutes. The next resident had 1 call at 37 minutes, another Resident had 7 calls with 1 at 15 minutes, 1 at 16 minutes, 1 at 17 minutes, 1 at 19 minutes, 1 at 40 minutes, 1 at 50 minutes and 1 at 96 minutes. LPA reviewed 7 randomly chosen resident care plans which revealed six out of seven (6/7) residents had care plans with additional services needed.