complaint·February 2, 2024

A review of documents revealed that in a single 7-day period it took 20 minutes or longer to answer 136 of the 1024 call alerts throughout the facility. For the week analyzed, 13.3% of the alerts took 20 minutes or longer to answer. Interviews revealed that facility staffing had declined specifically the number of care staff working at any given time. As a result, residents wait longer to receive care. This situation was ongoing and potentially affected all resident that required care. On one identified occasion Resident 1 (R1) (A list of confidential names was provided to the facility) pushed their call alert button. When no staff arrived to assist R1, an outside source became aware and attempted to contact staff members on behalf of R1. When no staff member could be reached by telephone, the outside source dialed 911. Documents revealed that facility staff did not respond to call alert for 45 minutes. The local emergency agency responded and found R1 required basic care that facility care staff then provided. The care was only provided after the emergency staff responded to the facility. Based on the evidence obtained during the complaint investigation, the allegation that the facility is not adequately staffed to meet resident’s needs is SUBSTANTIATED, meaning that there is a preponderance of the evidence proving that the alleged violation occurred. An exit interview was conducted with Silvia Garcia, Business Office Manager; a copy of this report and Licensee's Rights (LIC9058) were provided.