It was alleged that staff do not respond timely to residents' call lights. The investigation included interviews with staff and residents, observations, and a review of facility records. Based on the investigation, it was learned that the facility utilizes a call light system in each resident's room. Residents activate the system by pulling a cord, which illuminates a light outside the resident's room to alert staff to ensure that assistance is needed. The activation also appears on call panels located in the front lobby and at the nurse station. Staff then communicate via walkie-talkie with Resident Aides (RAs) regarding the resident's location and need assistance. LPA Lee interviewed five out of five staff members, all of whom denied the allegation and stated that resident call lights are responded to promptly. Additionally, six out of nine residents interviewed reported that staff generally respond to their call lights within five to ten minutes and expressed no concerns regarding delayed staff response times. During a facility visit conducted on 04/20/2026, LPA Lee observed and tested nine call light response events. Staff response times ranged from one to seven minutes, with an average response time of approximately three minutes. A review of facility records revealed that call light response logs were not available. The Administrator stated that the facility recently implemented a new call light system that remains in a trial phase and has not yet gone live; therefore, historical call log reports were unavailable at the time of the investigation. Based on interviews, observations, and records reviewed, LPA Lee was unable to corroborate the allegation that staff do not respond timely to residents' call lights.

CONTINUED LIC 9099-C

It was alleged that facility staff do not provide adequate supervision to residents. The investigation included interviews with staff and residents, as well as facility observations. LPA Lee interviewed 5 out of 5 staff members, all of whom denied the allegation. Staff stated that personal cell phone use is prohibited during working hours. Staff further explained that Resident Aides (RAs), medication technicians, and management are issued facility cell phones that are used as walkie-talkies to communicate regarding resident needs, call lights, and other operational matters. LPA Lee also interviewed 8 out of 9 residents, all of whom denied the allegation and reported no concerns regarding staff supervision or staff using phones while providing care. During the facility visit conducted on 04/20/2026, LPA Lee observed Resident Aides using facility-issued phones to communicate with other staff members regarding resident call lights activated in Rooms 110 and 115. LPA Lee did not observe staff using personal cell phones while on duty, nor were any residents observed to be neglected or unsupervised as a result of staff phone use. Based on interviews conducted and observations made during the investigation, LPA Lee was unable to corroborate the allegation that facility staff do not provide adequate supervision to residents.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.