Complaint Investigation Report

Facility does not ensure call bells are operable:

Staff are not ensuring to provide assistance to residents in a timely manner:

The allegations are the facility call button system is not working and residents did not receive assistance within timely manner.

On 01/27/2026, LPA interviewed Executive Director (ED) Marife Duewel. ED stated in end of December 2025, the facility had an unannounced power outage which damaged the facility call button system. ED stated the facility contacted the contracted maintenance company of the facility call button system. ED stated the company came to the facility to check/repair and stated it needed to replace the hardware and parts. ED stated the company stated it needed to order the hardware and parts to fix the problem.

ED stated the call button alarm notifications are still sent to the system's computer in real time but does not radio the alarm notifications to caregivers and Med Tech in real time. ED stated front desk staff were instructed to read the call button alarm notification log and notify caregivers and Med Tech to help residents. ED stated caregivers are instructed to tour resident rooms constantly to check if residents need assistance. ED stated management team and staff were instructed to help front desk to read call button alarm notification log and to call caregivers and Med Tech to help residents. ED stated the facility notified residents and families the issue of call button system.

LPA interviewed 9 facility staff. 9 Out of 9 staff stated the power outage damaged the facility call button system. 9 Out of 9 staff stated the call button alarm notification are still sent to the computer and the front desk staff notifies caregivers and Med Tech to help residents. 9 Out of 9 staff stated management team and staff help front desk to read the call button alarm notifications and call caregivers and staff to help residents.

LPA toured 8 resident rooms and interviewed 8 residents. LPA requested the 8 residents to press the call buttons and staff were observed coming in around 5 minutes. LPA interviewed 8 residents, 1 Out of 8 residents stated he/she yelled out and staff in the hallway came to help immediately. 2 Out of 8 residents stated they called front desk and staff came in to help. Both stated calling front desk for help is faster than using call button to receive assistance. 5 Out of 8 residents stated staff came in to help when they pressed call button.