Complaint Investigation Report

Physician’s Report for R1 (04/24/24), Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024) , Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and administrator Narine Mertkhanyan (A1) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit.

Allegation: Staff did not seek timely medical care for a resident

It is being alleged that facility staff failed to provide timely medical care after R1 experienced a fall, which resulted in a hospitalization for a leg fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1). During the interview conducted on 11/17/2024, Administrator Narine Mertkhanyan (A1) stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. A1 also reported that R1 was in hospice prior to being admitted and continued hospice with a nurse periodically checking on her throughout the night. On 12/23/2025, LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 5 out of 5 staff members denied the allegation. On 12/23/2025, LPA Troy Watson interviewed Residents #2–13 (R2–R13). Out of those interviewed 12 out of 12 residents denied the allegation.LPA Troy Watson obtained and reviewed facility and medical records for R1. Per R1’s Face Sheet, R1 was admitted to the facility on 10/29/2024. A Facility Internal Occurrence Report dated 10/31/2024 states that a caregiver reported R1 had an unwitnessed fall, after which the Wellness Coordinator assessed R1 and noted scratches to the hand but no other injuries. Facility Notes and Alert Charting dated 11/01/2024 indicate that the caregiver reported that on 10/31/2024, R1 was found on the floor. The 11/01/2024 charting also notes that a body check was completed, revealing no injuries other than to the left hand, although R1 complained of leg pain. Facility Notes and Alert Charting dated 11/02/2024 documents that the hospice agency requested an X-ray. LPA Troy Watson reviewed Vitas Hospice notes dated 11/01/2024 through 11/03/2024 which confirm that R1 remained at the facility during that period. On 11/04/2024, Facility Notes and Alert Charting indicate that R1’s family had R1 sent to UCLA Hospital.