complaint·October 16, 2025

Allegation: Facility staff did not address change in resident's condition. The complaint alleges that upon admission resident (R1's) responsible party was told that R1's diabetes would be managed, but it is suspected the resident died due to lack of insulin. It is alleged that one week prior to the resident's death their legs were observed to be swollen, but nurse staff did not address the change in condition. A total of seven (7) staff were interviewed. Staff denied the allegation. Based on record review, R1 moved in to the facility on May 31, 2024. Prior to moving in the resident resided at a skilled nursing facility. Records indicate that insulin medication was discontinued before the resident moved in. Record review and staff interviews revealed that the only change of condition was a urinary tract infection and an antibiotic medication was ordered by R1's health plan. A total of 7 residents were interviewed. Residents stated they are satisfied with the care provided and staff are responsive to health changes and needs. Some of the residents are diabetic, but only take oral diabetic medications. There is insufficient evidence to support the allegation. Allegation: Facility staff did not ensure the call button in resident's room worked. According to information obtained, resident (R1's) room signal system button was not working because on one occasion date unknown, resident (R1's) visitor was assisting the resident in transferring from wheelchair to the bed and the resident slipped. It is alleged resident (R1's) visitor pulled the call signal cord and no there was no staff response. Approximately 15 minutes later a staff passed by R1's room and assisted. All staff interviewed denied the allegation. They stated Memory Care Residents do not understand how to pull the call signal cord, but all call signal equipment is tested. Staff are equipped with phones that alert staff whenever someone uses the call signal system in the room. According to staff interviews, in early 2024 there were signal systems problems that were addressed. Maintenance staff tests the signal system monthly and/or as needed. A total of 7 residents were interviewed. None reported uses with their pendants or facility signal system. On 7/15/25, LPA tested the facility signal system in 22 rooms and pendant buttons. All room signal systems in the Memory Care Unit were tested. On 10/9/25, LPA tested the signal system in 20 rooms. During both dates the signal system was operational. Therefore, the allegation cannot be supported. *Report continues next page. Allegation: Facility staff did not ensure residents' had clean clothing to wear. It is alleged that in Summer 2024 staff took "Evergreen"/ Memory Care Unit resident (R1) to the dining room without pants. Resident (R1's) visitor found the resident with a small towel draped over their waist. Staff were questioned by the visitor and they allegedly said the resident did not have clean clothes to wear, and (R1's) visitor took the resident to their room to eat privately. A total of 7 residents were interviewed. The residents stated they are provided clean clothing, and have not observed any resident eating in the dining room without pants and/or bottom clothes. Most residents stated their clothes is washed on time. One (1) resident stated that there have been a few times they have had to call staff to inform them their laundry was not picked up, and that several clothing items were not returned with their laundry. None of the residents disclosed concerns about lack of clean clothes and issues with disrepair of facility washers. A total of seven (7) staff were interviewed. All staff denied the allegation. Staff interviews revealed that resident (R1) did not move in with enough clothing and family was reminded to bring the resident more clothes due to incontinence needs. Staff stated that if a memory care resident does not have clean pants, staff put pajamas on the resident prior to taking them out of the room. The allegation cannot be supported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation are Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to Leticia Garcia/