complaint·December 29, 2025

It was further alleged that staff did not respond timely to Resident 2’s (R2) call button in a timely manner. The investigation revealed that the facility care providers all have radios and they check with each other to see who is available to provide care when a call button is pushed. The MedTech on duty is responsible for monitoring the situation and will respond if all care providers are assisting other residents. It was also revealed that almost all calls are responded to from immediately to 10 minutes. On a rare occasion when all caregivers and the MedTech are busy assisting other residents, it might be 15 minutes before care can be delivered. No records were available to confirm response times. “Timely manner” is not specifically defined, however the preponderance of evidence revealed during the investigation did not confirm that response times are of regular concern or that any specific incident was egregious or endangered any resident’s wellbeing. This allegation is Unsubstantiated. It was lastly alleged that the facility did not provide adequate incontinence care for R2. Interviews with internal and external sources revealed that residents are checked every two hours to assess their toileting needs. Excluding the above allegation no concerns regarding resident incontinence care were revealed during the investigation. A review of documents did not reveal any skin breakdown for R1, or other indications of inadequate incontinence care. This allegation is Unsubstantiated. Based on the evidence obtained during the complaint investigation, the above allegations are UNSUBSTANTIATED, meaning the preponderance of evidence standard was not met. An exit interview was conducted with Risa Jester, Executive Director ; a copy of this report and Licensee's Rights (LIC9058) were provided.