Complaint·September 13, 2022

According to interviews, R1 pressed call button to receive assistance as described in facility service agreement and resident admission agreement. According to interviews, call button notification was not answered within the hour. According to interviews, R1 was experiencing an emergency medical occurrence. According to interview with witness, witness had to pull emergency call cord after pressing call button and getting no response. According to interview with direct witness, the facility did not answer the emergency call cord and the witness had to run through the facility to the business office to locate assistance. According to interview, call button was never answered during the emergency medical occurrence. According to interview with witness, 20 minutes had elapsed before resident was seen by staff. According to interview with RP, R1 pressed call button on several occasions for assistance to use the bathroom. According to interviews and document reviews R1 has had to wait from as long as 20 minutes to 2 hours for response to call button for bathroom assistance. According to interviews R1 has pressed the call button for assistance on 4 different occasions whereas the call button was not answered. According to interviews with S2 and S3, facility staff check to see if other staff is answering call buttons with the use of a walkie talkie. According to interviews, bedridden residents are waiting to get changed after pushing the call button for up to 30 minutes. In accordance with facility operation plan, and record reviews, response time to call buttons requests are targeted to be immediate and if not immediate, within a 3 to 5-minute timeframe. According to interviews with staff and residents, that time frame is not being adhered to. Therefore, residents are having to wait after pressing the call button if staff are on a break for as long as 30 minutes. Based on interviews with staff, there is a 2 to 3 ratio for caregivers and a 1 to 2 ratio of med techs in each hall at all times. Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted with Administrator James Hall, and a copy of the report was provided.