Complaint Investigation Report

Resident 1 (R1) moved into the facility in November 2024 with a diagnosis of senile degeneration of the brain. It was alleged R1 was over medicated on or around January 06, 2025 when a medicated topical cream was over applied. Per interviews with 2 out of 2 staff indicated they do not over medicate residents and they follow all physician’s orders. Per interview with hospice nurse there were no concerns about R1 being over medicated. Per review of medication administration records R1’s medication appear to be given as prescribed.

It was alleged that staff interfered with a resident’s telephone call. Per interviews with 2 out of 2 staff indicated that they have never interfered with resident’s telephone calls. 5 out of 5 residents interviewed stated their calls are not interfered with or interrupted.

It was alleged that staff did not ensure a resident consumed an appropriate amount of liquids in care. Per interviews with 2 out of 2 staff stated residents are provided water and liquids throughout the day and are encouraged to drink water. 5 out of 5 residents interviewed stated they have a water cup with them daily. LPA Mendivil observed all residents to have their own water cup near and the cups were full. Per interview with R1’s hospice nurse indicated there was no issues with R1’s hydration.

It was alleged that staff did not meet resident hygiene needs. Per interview with R1’s hospice nurse it was reported that hospice’s bath aid would come 3-4 times per week. Interview with hospice nurse reported that R1 appeared to be clean. Interviews with 2 out of 2 staff stated if R1 needed more assistance with hygiene they would provide assistance. Based on interviews with 5 out of 5 residents stated they are assisted with hygiene needs.

It was alleged that staff mishandled a resident’s pacemaker monitor. Per review if R1’s LIC 602 Physician’s Report dated November 20, 2024 did not mention a use of a pacemaker. No photographs, medical records or documentation could be found to verify the presence of a pacemaker for R1. Administrator Nargis Elahi stated no one told her about R1 having a pacemaker, but had they she would not unplug the monitor.

It was alleged staff retaliated against resident. Per interviews with 2 out of 2 staff stated they did not retaliate against any resident. Staff stated they have not acted negatively or rude to any resident. Interviews with 5 out of 5 residents stated the staff is kind and respectful.