complaint·March 18, 2026

The allegation is that staff did not answer resident's pull cord in a timely manner. On 09/03/2025, at 01:00AM, R1 pulled the emergency cord in his/her bathroom but the facility staff did not respond to it. ON 10/03/2025, LPA interviewed Executive Director (ED) Meghian Geul. ED stated the facility staff were not alerted when R1's call for assistance through his/her emergency cord on 09/03/2025 at 1:00AM. ED stated based on the emergency call alarm pull cord button log, the facility emergency call system did not receive the emergency notification from R1's room on 09/03/2025. ED stated there was training provided to staff and medication technicians that emergency pull alarm cord string cannot be tied on the toilet paper holder rack. On 10/03/2025, LPA interviewed Maintenance Director (MD). MD stated the maintenance department reviews the pull cord alarm system log every week to check for any issues such as low battery and fixes issues immediately. MD confirmed that the facility staff were not alerted when R1 called for assistance per alarm system log. On 09/03/2025 at 8:00AM, R1 called the front desk to inform that he/she had pulled his/her emergency alarm pull cord at 1:00AM but no one respond. A caregiver went to help R1 and checked R1's emergency alarm pull cord; and placed a work order to notify MD to check/fix. On the same day, at 10:00AM, MD stated he/she went to R1's apartment/bedroom to check on R1's emergency pull cord alarm. MD found that the emergency alarm pull cord string was tied/wrapped around the toilet paper holder rack tightly, and was unable to activate alarm when pulling the pull cord. MD stated he/she untied the emergency alarm cord string from the toilet paper holder rack, and R1's emergency pull cord was fixed and it alerts staff when pulling the emergency cord. MD stated that he/she provided training to facility staff including housekeepers prior to this incident reminding them not to tie or wrap emergency alarm pull cord to toilet paper holder rack. On 10/07/2025, LPA interviewed resident R1. R1 stated he/she was unable to remember if the emergency pull alarm cord string was tied or wrapped on the toilet paper holder rack on 09/03/2025 at 1:00AM. Continue on LIC9099-C. Page 2 of 3. On the same day, LPA noted that R1's emergency pull alarm cord string was untied to the toilet paper holder rack. LPA also tested by pulling the emergency pull alarm cord, and 2 staff came into R1's room within 5 minutes. LPA also tested the emergency pull alarm cord system by tying it on the toilet paper holder rack to see if pulled would alert staff radio while the 2 staff were observing, staff radio did not alert them. Based on interviews, record review and inspection of R1’s Emergency pull alarm cord and emergency log confirms that staff did not alert them when R1 called for assistance. It was discovered by staff that R1’s emergency pull alarm cord was wrapped or tied to the toilet paper holder rack which prevents it from activating. The Department has investigated the above allegation. Based on the investigation, records reviewed, observation, and interviews conducted, the Department found that the above allegation is UNFOUNDED , meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED. Page 3 of 3.