Complaint·February 26, 2025

Executive Director/Administrator, Elena Cuevas (AD), also addressed the call light response times, stating that the average response time for call lights is currently at approximately 8.5 minutes. AD confirmed there have been no issues with staffing shortages during the night (NOC) shifts. The facility ensures adequate staffing by utilizing outside agency personnel when necessary, such as in cases of call-ins or when other staff members are unavailable. Further corroborating this, a review of call light/pendant response records for January and February 2025 indicated that the average time to take an alert was approximately 7 to 9 minutes. The response times for staff to reach residents ranged from 9 to 11 minutes, with an average of around 7 minutes spent with residents. The types of assistance provided during these interactions ranged from toileting and transferring to emotional support, medication administration, and addressing falls, among other needs. Additionally, a review of the facility’s staffing schedule for the night (NOC) shifts in both the Assisted Living (AL) and Memory Care (MC) areas confirmed that at least two care staff members in the MC area and two care staff in the AL are scheduled during each NOC shift, along with a med tech on duty. Based on the interviews and record reviews, there is no preponderance of evidence to substantiate the allegation that facility staff are not awake or unavailable during overnight hours when residents require assistance. The facility has measures in place to ensure staff are attentive during the night. Therefore, the above allegation was deemed UNSUBSTANTIATED. Exit interview was conducted and a copy of this report and appeal rights were provided. {2 of 2}