Inspector’s narrative
What the inspector wrote
On 08/13/2025, LPA Jeffries reviewed the facility provided call button response schedule for R1’s room from 06/24/2025 through 07/17/2025 (24 days) Tilted: Resident Incident Details Report: This report shows a total of 668 Resident Incident calls from R1’s room. Of those 668 calls, 221 calls took over 10 minutes for staff to respond to clear call button (33% of calls); of those 221 calls over 10 minutes, 86 (13% of calls) of the calls took over 20 minutes for staff to respond and clear. Serious Incident Report (SIR) from facility dated 06/24/2025 shows R1 calling 911 for chest pain at 9:50pm, on 06/24/2025 the last call button for R1 was pressed at 6:58pm and shows 42 minutes and 39 seconds to clear (42:39). SIR dated 06/29/2025 shows R1 calling 911 for chest pain at 12:30pm, the last call button press for R1 prior to time on this SIR was 12:16pm with staff clearing call 30 minutes and 14 seconds (30:14) later when Emergency Medical Technicians (EMT) arrived to the facility for R1’s 911 call, R1 refused transport at that time. SIR dated 06/30/2025 shows R1 called 911 for back pain at 7:30am. R1’s last button press to this SIR was 7:09am, 24 minutes and 23 seconds later (24:23) that call button press was cleared. SIR dated 07/03/2025 shows R1 calling 911 at 8:50am, R1’s last button press to this SIR was at 7:58am, call button was cleared 39 minutes and 26 seconds (39:23) later. SIR dated 07/04/2025 at 9:00pm showed R1 called 911 due to throat closing, the last call button press in relation to this SIR was 8:49pm, log shows this call button being cleared 32 minutes and 40 seconds (32:40) later. LPA noted that 5 SIR’s for calling 911 all show call response times by facility staff exceeding 24 minutes or more. LPA noted that on 04/03/2025 the facility was cited on a complaint for required signal system [87303(i)(1)(C)]. and as the plan of correction for that citation was to have all pendants (call buttons) reprogrammed by 04/17/2025. This POC was confirmed by email on 04/17/2025 that all pendants were working. Based on 33% of the button calls for incident for R1’s room took 10 minutes or more for staff to respond and 5 documented SIRs showing call times exceeding 24 minutes, and interviews, there is enough evidence to support the allegation of ““Staff do not respond to resident call for assistance in a timely manner” and is substantiated at this time.
Exit interview, report read, citation issued, report and appeal rights provided.
The next time R1’s call button was pressed was 3:50pm, approximately 7 hours in between calls and approximately 6 hours after R1 called F1 to alert for incontinence. According to F1’s interview, R1 had been changed by staff on or before 10:15am on 07/11/2025. However, there was no call button to summon staff for assistance from R1’s call button after 8:56am. On 07/14/2025, LPA interviewed Direct Care Staff (S1, S2, and S3), all stated that R1 required at least 2-person assist with incontinent care and showering but only wanted assistance from direct care staff who was not on duty during the day shift and refused direct care assistance for incontinence and showering. Based on interviews of F1 stating staff had difficulty helping R1, with cleaning and changing on 07/11/2025, and no indication of call button being pressed at time alleged in complaint, staff and R1’s interviews of R1’s right to refuse, and documentation there is not enough evidence at this time to support the allegation of, “Staff do not ensure that resident's toileting needs are met”, “Staff do not ensure resident's showering needs are met.” and are unsubstantiated at this time.
As to the allegation of, “Staff handled residents in a rough manner.”, it was alleged that R1’s first day at the facility, 5 direct caregivers attempted to change R1 in a rough manner. It was discovered through interviews, and documentation that on 07/14/2025 LPA conducted an interview with F1 and R1, who stated that 4 staff members were trying to move R1 in ways that worked for them and not R1, and one staff member was just watching and not helping. On 07/11/2025 In interviews with S1, S2 who were working on 06/24/2025. S1 and S2 stated that R1’s behavior in the incontinent change that day made it difficult for staff to change R1 and they were attempting to work with R1 to make it work in light of the behavior to resist the assistance of staff. S1 and S2 stated, there was only room for 4 staff to help and they do not remember the 5th staff present on 06/24/2025. On 07/14/2025, LPA reviewed staff training on all facility direct care staff members, all staff are current and up to date on annual regulated training requirements which included training on resident transfers. On 08/13/2025 LPA reviewed R1’s Resident Assessment, which indicated that R1 required a 2 person assist with transfers, bathing, toileting, and dressing. Based on interviews indicating resisting staff care and documentation of regulated staff training, there is not enough evidence at this time to support the allegation of, “Staff handled residents in a rough manner.” and is unsubstantiated at this time.
CONTINUED on LIC9099-C
As to the allegation of, “Staff so not provided adequate food service.” It was alleged that staff leave food for R1 across the room, where R1 could not reach food. It was discovered through interviews that on 07/14/2024 LPA conducted interviews with R1 who stated that they do not like the food at the facility. R1 stated,” a few days ago (did not remember specific date) dinner was delivered when I was sleeping and when I woke up it was cold. R1 stated that they had to call staff (via call button) in order to reach dinner.” On 07/11/2025, LPA interviewed S1, S2, and S3, all who stated that they had never seen meals being placed out of reach of R1’s bedside. On 08/13/2025, LPA reviewed facility’s call button report for R1’s room, which shows approximately 650 calls for service answered in a period of 22 days. On 07/14/2025, LPA reviewed R1’s Physicians Report (LIC602) singed and dated on 06/24/2025, which indicated that R1 is “able to feed self”. And Facility Resident assessment dated 06/27/2025 which indicated that R1 “Requires food cut chopped, pureed, or otherwise prepared.” With no other assessments pertaining to meals. Based on documentation, interviews, and staff observations, there is not enough evidence at this time to support the allegation of, “Staff do not provide adequate food service.” and is unsubstantiated at this time.
Exit interview, report read, and report provided.
