Complaint Investigation Report

On 08/13/2025, LPA Jeffries reviewed the facility provided call button response schedule for R1’s room from 06/24/2025 through 07/17/2025 (24 days) Tilted: Resident Incident Details Report: This report shows a total of 668 Resident Incident calls from R1’s room. Of those 668 calls, 221 calls took over 10 minutes for staff to respond to clear call button (33% of calls); of those 221 calls over 10 minutes, 86 (13% of calls) of the calls took over 20 minutes for staff to respond and clear. Serious Incident Report (SIR) from facility dated 06/24/2025 shows R1 calling 911 for chest pain at 9:50pm, on 06/24/2025 the last call button for R1 was pressed at 6:58pm and shows 42 minutes and 39 seconds to clear (42:39). SIR dated 06/29/2025 shows R1 calling 911 for chest pain at 12:30pm, the last call button press for R1 prior to time on this SIR was 12:16pm with staff clearing call 30 minutes and 14 seconds (30:14) later when Emergency Medical Technicians (EMT) arrived to the facility for R1’s 911 call, R1 refused transport at that time. SIR dated 06/30/2025 shows R1 called 911 for back pain at 7:30am. R1’s last button press to this SIR was 7:09am, 24 minutes and 23 seconds later (24:23) that call button press was cleared. SIR dated 07/03/2025 shows R1 calling 911 at 8:50am, R1’s last button press to this SIR was at 7:58am, call button was cleared 39 minutes and 26 seconds (39:23) later. SIR dated 07/04/2025 at 9:00pm showed R1 called 911 due to throat closing, the last call button press in relation to this SIR was 8:49pm, log shows this call button being cleared 32 minutes and 40 seconds (32:40) later. LPA noted that 5 SIR’s for calling 911 all show call response times by facility staff exceeding 24 minutes or more. LPA noted that on 04/03/2025 the facility was cited on a complaint for required signal system [87303(i)(1)(C)]. and as the plan of correction for that citation was to have all pendants (call buttons) reprogrammed by 04/17/2025. This POC was confirmed by email on 04/17/2025 that all pendants were working. Based on 33% of the button calls for incident for R1’s room took 10 minutes or more for staff to respond and 5 documented SIRs showing call times exceeding 24 minutes, and interviews, there is enough evidence to support the allegation of ““Staff do not respond to resident call for assistance in a timely manner” and is substantiated at this time.

Exit interview, report read, citation issued, report and appeal rights provided.