Complaint Investigation Report

by staff. Asmik Nadrian, Administrator/Licensee was contacted by staff and was not reachable via phone and did not participate in the visit. The facility also did not have evidence of a designated responsible staff when the Administrator is not present at the facility. During the visit LPA Yee toured the facility at 1:15pm, no immediate safety concerns were observed for the physical plant. The LPA reviewed the food supply at 1:30pm, observed 4 residents in care at 1:40pm, and reviewed 6 resident files at 10:30am. Copies of files for Resident #1 (R1) and Resident #6 (R6) were obtained. No interviews were conducted as staff present had no information or spoke very limited English. Marine Arshakyan, administrator arrived around 1:20pm. Per Marine, she became co-administrator about 6 years ago. The LPA determined further investigation was required prior to issuing findings .

Investigator Spindola conducted interviews on 11/29/2023, from approximately 12:00pm to 1:00pm, with the administrator, staff, and co-administrator; on 12/28/2023, from approximately 8:20am to 9:40am, with the administrator, residents, and staff; on 01/10/2024, at approximately 11:00am, with R1’s resident representative; on 01/18/2024, at approximately 11:30am, with R1; and on 01/30/2024, at approximately 9:30am, with the administrator. In addition, the investigator reviewed Providence Saint Joseph’s Hospital (PSJH) medical records and facility file documents related to R1.

According to R1’s physician’s report, dated 07/08/2022, R1’s diagnosis included hypertension, heart disease, diabetes type 2, and major depression. The report listed mild cognitive impairment (MCI) and a special diet due to diabetes and hypertension.

The investigation revealed that on 10/07/2023, R1 was hospitalized at Providence Saint Joseph’s Hospital (PSJH). The PSJH records indicated that R1 was diagnosed with “…pneumonia of both lungs due to infectious organism, unspecified part of lung...epigastric pain, gallbladder necrosis, sepsis, metabolic encephalopathy, cholecystitis …Successful ultrasound guided percutaneous cholecystostomy…Status post cholecystostomy tube placement…Continue antibiotics…”. R1 was released to the facility on 10/20/2023. Staff interviews revealed that upon R1’s discharge back to the facility on 10/20/2023, R1 could not eat solid food and was given Ensure protein drinks. Per R1, when