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Complaint Investigation Report

Montgomery Springs Manor, Hayward02/14/2025Licence 015601506

Census13
Date signed02/14/2025 05:37:08 PM
The inspector’s account

Review of records showed facility has copy of ePrescription dated 2/01/25 with antibiotics prescribed 3 times a day for 3 days with out-of-state pharmacy listed and with comments 'deliver by CPN tomorrow'. This document showed received 2/06/25. PCP1 stated that PCP1 prescribed the antibiotics on 1/31/25 and that if the medications need to be delivered immediately, it should be delivered by the local pharmacy. PCP1 stated that it could be pharmacy issue that the medication was not delivered the following day the prescription was written. S1 stated she only came to know about the prescription and was only informed by R1 once. S1 and ADM stated they called the Center for Elder's Independence to follow-up. S1 stated the medication was received on 2/06/25 and started the administration dinner time on 2/06/25. Based on information gathered, the allegation is unsubstantiated.

R1 stated that residents have to put their used (soiled) toilet paper in the garbage because they are not allowed to flush the toilet paper in the toilets. R1 also stated that staff tell residents to use the garbage because if they flush the toilet paper the toilets get clogged up.

LPA conducted inspection and flushed all the toilets. LPA observed all the toilets draining properly. The 3 staff, ADM and R2 stated the toilet in the big bathroom was not draining properly but did not overflow, and was replaced with a new one recently. Therefore, the allegation is unsubstantiated.

Allegation: Staff not treating resident with respect and dignity.

R1 stated that when R1 was asking S1 about R1's antibiotics medication, S1 told R1 to shut up. S2 and S3 stated not hearing S1 and denied telling R1 such. R2 stated not hearing S1 or other staff respond to any residents inappropriately. Therefore, the allegation is unsubstantiated.

Based on review of records, interviews and inspection, the 3 allegations are closed as unsubstantiated. A finding that a complaint is 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 violations occurred.

Exit interview conducted and copy of this report provided.

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction