Complaint·April 30, 2025

Interviews with staff and residents revealed the facility’s front desk phone line was transferred to a cordless phone after 7pm. The cordless phone was them answered by the medication technician on duty. Some interviews revealed there were occasions when the phone malfunctioned and calls would not go through, but this was addressed promptly. Residents were advised to use the call pendant for emergencies, falls, and incontinence care. Residents were encouraged to call the front desk for any other services required. Interviews with staff and residents revealed residents were still able to press the call pendants when the front desk phone line was not operating properly. Residents did not report any concerns with lack of medication assistance, nor concerns with staff not responding to pendant calls. Residents did not recall being discouraged from using the pendants to summon staff for assistance. An interview with R1 confirmed R1 was not part of the facility’s medication management program. R1 confirmed R1 had additional dosages of the medication in question, and R1 did not miss a scheduled dose. R1 confirmed housekeeping staff retrieved R1’s medication on a subsequent day. Although some interviews revealed conflicting statements on if residents were encouraged, or discouraged to use the call pendants; the interviewed residents did not have any concerns with staff not responding to pendant calls for assistance. Therefore, the allegation was unsubstantiated. An exit interview was conducted with Lopez, to whom a copy of this report, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058), were provided.