Facility Evaluation Report

On 10/21/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the community to conduct a case management. LPA Campbell met with Andrea Eldridge, Memory Care Director, and explained the purpose of the visit.

During the course of the visit, LPA Campbell spoke with S1 regarding the call button system and procedure, reviewed the PalCare alert system, and spoke with the S2 about prior and ongoing issues with the pendant system. Per S1, under 15 minutes is an acceptable response time for pendant calls though there there may be longer response times during med pass or meal times. S1 reported that when residents use their pendants, notifications are sent both to a department computer screen and the phone. If there is no response, the notification is sent to the front desk where the front desk staff can radio for assistance until the alert is cleared. The front desk is available from 8 am to 8 pm.

LPA Campbell then worked with staff to produce a report that showed all alerts for R1 for the past month. Upon review of the Detailed Alert Report for R1 from 09/20/25 to 10/20/25, 20% of the pendant calls received had a response time longer than 15 minutes and 6% of the pendant calls had a response time longer than 30 minutes. Per S2, there are ongoing issues with clearing alerts and/or staff receiving alerts. S2 reports that pendant alerts either cannot be cleared or are not being received by staff.

LPA Campbell and S1 discussed alternatives for the pendant that are more consistent. S1 was urged to ensure staff document all bed checks and to increase checks for R1 when they are on the way, or returning from other residents checks. LPA Campbell also discussed staff using active listening skills and showing empathy to residents and families to de-escalate emotional conversations.