| LPA interviewed staff and 6 of 7 staff have informed LPA that the call system has always been operational. 6 of 7 staff revealed that if a call light is malfunctioning, the maintenance director fixes it right away and does not delay fixing the issue. 6 of 7 staff informed LPA that the response time is expected to be 10 minutes or less. 6 of 7 staff informed LPA that all calls are responded to no matter what. 6 of 7 staff informed LPA that the call lights give a notification when the batteries are low. 1 of 7 staff work in the business office and do not attend to call light signals.
LPA interviewed residents and 7 of 7 residents informed LPA that their lights were operational. 7 of 7 residents informed LPA that their chords have always been operational. 6 of 7 residents informed LPA that staff always respond to the light and assist them. 1 of 7 residents informed LPA that the staff do not always respond to the signal system.
Regarding the facility allegation of Facility is not maintained in conformity with the regulations adopted by the State Fire Marshal revealed the following: It was alleged that the electrical facility plugs were not operational or mounted to the wall correctly. LPA observed all plugs to be on the facility wall to be placed correctly and no wires were exposed. LPA did not observe any reports stating the plugs were not operational in 2022.
Regarding the facility allegation of Facility staffing is inadequate to meet resident's needs revealed the following: It was alleged that due to a high turnover of staff, resident needs are not being met. LPA was unable to review staff schedules for the year of 2022. LPA observed a current staff schedule that reflected 5 care staff are on the morning shift, 5 care staff are on the evening shift and 2 care staff are on the over night shift.
LPA observed an in service that was conducted on October 15, 2025, on the topic of call light responses and resident communications.
Interviews with 7 of 7 residents revealed to LPA that the staff assist them and their needs are taken care of. 5 of 7 residents informed LPA that they are more independent and do not need as much assistance. 2 of 7 residents informed LPA that they get assistance whenever needed even for things that do not pertain to their care.
Based on information gathered and interviews conducted, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegations are deemed UNSUBSTANTIATED.
An exit interview was conducted and a copy of this report was left at the facility.
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