complaint·October 30, 2025

Regarding: Staff did not respond to resident's call button in a timely manner. It is alleged that resident pulled their call button but no one went to their room, even after pressing the button three more times. It is also alleged that staff finally went to resident’s room after three hours of the button being pulled. Staff deny the allegation. Interviews with (8) out of (8) staff revealed that staff respond to residents who push their call button in a timely manner. Interviews with staff indicated that staff do not wait three hours to check in on a resident if their call button was pushed. Staff indicated that if a call button is pushed and the staff assigned to check in on a resident is attending to another resident’s needs, front desk staff will call on other staff who are available to check in on resident who called for help. Staff further indicated that although their resident assignments call for them to check on residents every two hours, checks on residents are ongoing during staff rounds. Interview with (14) out of (15) residents indicated that staff respond in a timely manner to their calls if they activate their call button. Residents further indicated that they have no concerns regarding staff not responding in a timely manner to calls made using their call button. Staff did not follow resident's care plan. It is alleged that resident’s care plan states that staff need to check on resident every two hours because they are a fall risk and they have a medical condition. Staff deny the allegation. Interviews with (8) out of (8) staff revealed that staff check on all residents who live in the facility every two hours and during ongoing walks through the facility. Staff indicated that all residents get visits from staff whether they are independent, on hospice or require full care. Staff further indicated that residents’ care plans are followed to ensure residents’ needs are met appropriately. Interviews with (14) our of (15) residents indicated that staff check in on them every two hours or sooner. Residents further indicated that staff conduct visit to their rooms and also look for them in the common areas of the facility to check in on them. Residents stated that they have no concerns with staff not checking in on them every two hours or not following their care plan. Based on interviews, the allegations could not be corroborated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated . An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.