Complaint·November 19, 2024

[CONTINUED FROM LIC 9099] CCLD studied the signals data for six (6), randomly selected, twenty-four-hour days, chosen from the complaint allegation period. During the surveyed days, there were a total of 227 resident pendant calls, of which 182 (or 80.2%) were answered by staff in ten (10) minutes or less, and of which 206 (86.3%) were answered by staff in fifteen (15) minutes or less. Work schedules showed that on the surveyed days, Licensee consistently utilized third-party staffing agencies, when needed, to plug/fill staffing vacancies which were not already filled internally by facility caregivers. Interviews of Medication Technicians and Caregivers showed a pattern of teamwork, communication, and clarity of expectation, as it related to responding to resident signal alerts. Staff interviews and documentation further showed that facility managers met several times per week to review and discuss signals report data, from a quality assurance standpoint. Based on the totality of records and interviews, a preponderance of evidence does not exist to show that Licensee’s staff did not timely respond to resident signals/alerts. The allegation was therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Boeddeker, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099] Interviews showed: After P1 slipped and fell in the facility’s dining room, they told staff they had pain in their hip. There was brief hesitation from facility staff about whether they could call 911 for P1. Ultimately, another visitor of the facility called 911 for P1. (Interviews showed the delay being somewhere between three and ten minutes. The delay was not consequential for P1’s subsequent treatment/recovery). Based on records and interviews, the allegation that Licensee did not arrange medical care for resident in care is Unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The Department has therefore dismissed the allegation, and no deficiency was cited for it. During today’s visit, LPA provided Technical Assistance (TA) to Licensee regarding CCR 87411 Personnel Requirements – General (refer to the LIC9102 page). An exit interview was conducted with the Boeddeker, to whom a copy of this report, the LIC9102 page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.