Complaint·November 18, 2025

Staff stated that when they became aware of the call for assistance to R1, staff had to complete assistance with another resident on the second floor. Some staff reported that pagers used by staff were unreliable- sometimes not working and sometimes delayed signal. Management denies hearing of such issues with pagers. Staff, responding to R1 on 8/28/25, were told by R1’s spouse that they had been calling for assistance for a half an hour. Additionally, it was reported that after waiting for call button response, R1’s spouse, reportedly, called to the front desk before assistance arrived. Therefore, it is found that personnel were not sufficient in numbers to meet the needs of residents. Records and statements found that on 6/28/25, R1 was hospitalized for an acute health condition. Following their return to the community, R1’s services plan was increased to include evening and overnight assistance for R1’s safety . Statements by staff and the Administrator found that the increased assistance was not consistently provided as agreed to R1 during this time. R1’s condition improved to no longer needing the increased assistance. The service was discontinued and R1 was reimbursed for the lapse in increased care. Therefore, personal assistance and care, as identified, was not provided to R1 and as indicated in R1’s service agreement. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with . Copy of this report and appeal rights provided.