Complaint·October 21, 2025

On the allegation: Staff left residents in soiled diapers for an extended period of time. The administrator stated our goal is to respond to call lights usually within 10 minutes, many times when residents use their call button it is not always an emergency. LPA De Leon reviewed Call Pendant Logs from 09/06/2024-09/25/2024 (20 Days) for Assisted Living only at the facility which revealed over 555 pendant call logs showed a clear time from 15 minutes to 81 minutes. Witness 1 (W1) stated resident 1 (R1) needs assistance with toileting and on several occasions the resident has had to sit soiled for 45 plus minutes after requesting help by pressing the pendant call button. R1 had a total of 91 calls during the 20-day period review of the logs which revealed 11 call button calls over 15 minutes to 31 minutes. LPA reviewed call button logs and for calls over 15 minutes requested and reviewed 42 resident care plans. The care plans were reviewed for Toileting which revealed out of 42 residents 15 residents had a care plan for Extensive Assistance with Toileting, 5 residents were Total Assistance with Toileting, 5 residents had Moderate/Minimal Assistance with Toileting, and 17 residents were Independent with Toileting and out of those residents 10 may still call for help if needed or needed reminders or queuing and 5 residents were completely Independent in toileting. LPA reviewed a recent call button logs for assisted living from 08/01/2025-08/07/2025 for 7 days which revealed a large amount of calls over 15 minutes and up to 40 minutes. Staff interviewed revealed in 2024 they were short staffed and as of recently are filling positions and it is getting better. Agency staff were largely used in 2024 and have been cut back some, but the facility is still using agency staff to fill in for vacant, vacations or sick call offs when needed. Staff said it is their goal to answer call buttons within 10 minutes, but that time cannot always be maintained due to the needs of the residents as many residents need standby assistance, 1 or 2-person staff transfers and 2-person Hoyer lifts. Staff said they do get a list of residents that they are responsible for daily meeting their needs but when call button alarms come in and they are busy caring for a resident they cannot take the call, and the next available caregiver takes it. Resident interviews revealed when the call button is used, and it can take a long time to get assistance. They feel the facility needs more staffing and staff at the facility work hard and try to get everything done for the residents but at times it can take a while. Residents also stated the Agency staff do not do as good of job, only do the bare minimum and are not as caring as the regular facility staff. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Staff did not communicate with resident's authorized representative in a timely manner. LPA interviewed Staff and residents which revealed the resident’s responsible parties are notified of an incident by the medication technicians (Med-Tech) or the Nurse. Most felt the notifications are being made. R1’s responsible party (RP) said there was an incident in June and September 2024 with R1 and the RP was not notified. Community Care Licensing (CCL) was provided with incident reports for both of those incidents and on the paperwork, it was written the RP was notified by leaving a voice mail message. The RP said she did not have voicemail left on either incident. A staff stated sometimes during shift change or when an emergency happens, they do feel all RP’s or families are notified because of shift change and the communication between the Med-Techs, other med-techs coming on shift and Nurse is not always good. LPA requested incident reports from the facility for the months of June and September 2024 and only 1 report was provided for R1, LPA asked again for any other reports and was told there were not any, even though in CCL records two reports were sent by the facility for R1. A recent complaint was filed and one of the allegations was regarding the reporting of incidents to the RP or family in which family members were not notified. Based on the evidence this allegation is Substantiated at this time. This will not be cited in this report due to being cited on other complaint. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Director of AL.