During today's visit starting at 10:20 a.m. LPA and DMC briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 10:40 a.m. and through the visit conducted nine (9) in person resident interviews, five (5) staff interviews including one (1) med tech, two (2) caregivers also known as PALS within the community and a record review of the call response report / alarm exception report from 11/15/2025 – to 01/06/2026 and excessive delay log.

On the allegation, due to lack of staff, call bells are not answered timely, it is the concern of the Reporting Party (RP) that due to the lack of staff residents are waiting over 30 minutes for assistance with toileting. To investigate this complaint, LPA conducted in person staff interviews, in person resident interviews, record review, and obtained copies of pertinent documentation relevant to the investigation.

Interviews with the DMC revealed that the facility is staffed according to their acuity report. The facility typically staffs six (6) caregivers/PALS on first shift, five (5) on second shift, and two (2) on NOC shift. To their knowledge, the facility is staffed appropriately and resident needs are being met. Call times may vary; however, all calls are addressed promptly to assist residents. DMC reported that residents are not waiting for extended periods for toileting assistance, and no complaints have been received regarding prolonged wait times. It was noted that the facility does experience call-outs; however, management makes efforts to cover areas of need. Interview with the DRC revealed that the facility resolves all call button requests. They do not have any unresolved requests. The goal is to respond as quickly as possible, ideally within 20 minutes.

Interviews with facility staff, including two (2) memory care caregivers/PALS, four (4) assisted living caregivers/PALS, and one (1) med tech, revealed that the facility is at times short-staffed, resulting in longer wait times and a heavier workload. Staff reported that they do their best to address requests as promptly as possible, ideally within 20 minutes. It was noted that when staff are actively assisting residents and additional calls come in, they typically check in with residents to assess the severity of the request and respond accordingly. Assisted living caregivers/PALS reported that, at times, due to limited staffing, residents may wait up to 20 minutes for toileting assistance however are always assisted as promptly as possible.

Report continued on LIC 9099-C PAGE 3...

Interviews with residents revealed overall satisfaction with staff; however, they noted a decrease in staffing levels across all departments. Residents are typically attended very promptly, though response times can be slightly longer when fewer staff are present. Residents reported no extended wait times when requesting assistance, with staff generally responding within 10 minutes and sometimes immediately. Residents also reported no extended wait times for toileting assistance and stated they have no concerns at this time regarding call response times.

Record review of the call response report/alarm exception report from 11/15/2025 to 01/06/2026, along with the excessive delay log, revealed that all call requests had been resolved. The excessive delay log showed that the most recent extended response time occurred on 11/30/2025 at 7:20 p.m., with a response time of 37 minutes and 15 seconds. It was documented that staff were in the room providing care to a resident and the pull switch had not been restored. Staff were reminded to restore the switch upon entering the room. No other excessive delays were noted in the response times from 11/15/2025 onward.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Due to lack of staff, call bells are not answered timely is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.