Inspection Reports for
Melrose Gardens

The complaint investigation was unsubstantiated. Allegations included staff not safeguarding resident's personal belongings and not allowing a resident to have visitors. The visitor was prohibited due to aggressive behavior and health and safety risks, but the allegations were ultimately unsubstantiated.

The investigation found insufficient evidence to substantiate the allegation regarding safeguarding of personal belongings. The allegation that staff did not allow a resident to have visitors was also deemed unsubstantiated, as the visitor was prohibited due to health and safety concerns for the resident and others.

The complaint investigation was unsubstantiated based on observations and interviews. Allegations included inadequate food service, unsanitary conditions, and unclean linens, all of which were found to be unproven.

The investigation found no evidence to support the allegations. Observations and interviews with residents indicated that meals were adequate, the facility and resident's room were clean and sanitary, and linens were clean and properly maintained. Therefore, all allegations were deemed unsubstantiated.

The facility was found to have no health and safety hazards at the time of inspection. Fire safety systems, medication storage, laundry areas, and staff records were all observed to be in compliance and properly maintained.

The complaint investigation was unsubstantiated. Allegations included staff leaving medications unattended and not ensuring residents took them, and staff not knocking before entering residents' rooms. Interviews and observations did not verify these allegations.

The investigation found insufficient evidence to substantiate the allegations. Observations and interviews indicated no medication was left unattended and staff generally respected residents' privacy by knocking before entering, though one resident reported otherwise. No health and safety hazards were noted.

The facility was inspected for cleanliness, safety, and compliance across multiple areas including physical plant, kitchen, resident bedrooms, bathrooms, common areas, and outdoor spaces. Resident records were reviewed and found to be complete and current. The inspection was not fully completed due to time constraints and will be finished at a later date.

The complaint was unsubstantiated based on record reviews, interviews, and observations. The allegations regarding inadequate food service and communication issues were not verified.

The investigation found that a variety of well-balanced foods were offered and served, and staff reported offering meal alternatives and effective communication with residents. Some residents stated the food was inedible and no options were offered, but most residents were satisfied. Overall, there was insufficient evidence to substantiate the allegations, and no health or safety hazards were noted.

The complaint alleged that staff were aware of a resident entering another resident's room multiple times but neglected to address it. Interviews and observations did not support this claim, and the allegation was unsubstantiated.

The investigation found no health or safety issues and interviews with staff, residents, and the Executive Director indicated that residents have locks on their rooms and staff actively monitor wandering residents. The allegation was deemed unsubstantiated.

The complaint alleged that staff do not answer the facility telephone during morning and afternoon hours and that visitors are unable to enter or leave due to lack of front desk coverage. The allegation was found to be unsubstantiated based on observations and interviews.

The investigation found that the telephone was in working order, staff consistently covered the front desk, and interviews with staff and residents confirmed no issues with telephone answering or visitor access. The allegation was unsubstantiated.

The complaint alleged that staff failed to distribute Resident#1's medications as prescribed and failed to safeguard personal belongings of Resident#3 and Resident#4. After review of records, observations, and interviews, the allegations were found unsubstantiated.

The investigation found no evidence to support the allegations. Medication distribution was confirmed to be as prescribed, and residents' personal belongings were safeguarded. Therefore, both allegations were deemed unsubstantiated.

The complaint alleged inadequate incontinent care and failure to meet hygiene needs for Resident 1. The investigation included interviews with staff, the resident's family member, and review of medical and assessment records. The allegations were unsubstantiated as evidence showed the resident's needs were being met.

The investigation found no evidence to support the allegations. Observations, record reviews, and interviews indicated that the resident was clean, dry, and able to perform most activities of daily living with minimal assistance. Therefore, the allegations were deemed unsubstantiated.

The inspection found that fire detection and protection systems were functional and properly maintained, medication storage and documentation were secure and complete, laundry and common areas were clean and safe, resident bedrooms and bathrooms met safety and comfort standards, and resident and staff records were complete and current. No immediate health or safety hazards were observed.

The facility was found to be clean and well-maintained, with proper infection control measures and safety systems in place. Resident records were complete and current, and the kitchen met all health and safety standards. The inspection was not fully completed due to time constraints and will be finished at a later date.

The complaint included allegations that staff did not ensure good quality and quantity of food, were rude to residents, and did not properly manage medications. The investigation found these allegations unsubstantiated based on observations, interviews with staff and residents, and review of medication records.

The investigation found that the facility had sufficient food stock and residents reported food quality and quantity as good. Staff were not found to be rude to residents, and medication management issues were related to insurance coverage and physician restrictions. All allegations were deemed unsubstantiated.

Complaint investigation associated with complaint report #31-AS-20240425102904; initial investigation visit conducted on 2024-04-30. The amended complaint investigation report was delivered on 2024-05-29.

The report documents the delivery of an amended LIC 9099 Complaint Investigation Report to the Assistant Administrator, Jennifer Rivera, summarizing the complaint investigation findings.

The complaint alleged that staff prohibited a resident from having visitors. The investigation revealed that the family member was restricted from visiting by their own facility's medical team pending a medical evaluation. The allegation was unsubstantiated.

The investigation found no issues with visitation rights; the facility does not prohibit residents' visitation. The family member in question was temporarily unable to visit due to medical restrictions at another facility. The allegation was unsubstantiated.

Complaint was substantiated. Allegation was that staff did not order resident’s medication refills in a timely manner. Investigation confirmed medication refill delays and inaccurate medication administration record keeping.

The investigation found that medication for Resident #1 was not refilled in a timely manner, resulting in a medication gap from 01/03/2024 to 01/08/2024. Additionally, staff continued to initial medication administration records for Resident #1 after the resident had relocated, indicating inaccurate documentation. These findings were substantiated and posed immediate health and safety risks.

The inspection found that all four emergency exits equipped with delayed egress systems were operational and functioning properly. The facility was in compliance with Title 22 Regulations and had no deficiencies.

The inspection found that 2 out of 6 exit doors equipped with the Delayed Egress Locking System (DELS) were not operational or functioning properly, resulting in non-compliance with Title 22 Regulations at the time of the visit.

The facility was generally clean, well-maintained, and equipped with operational safety features; however, it was found not in compliance due to delayed egress doors on the 1st and 2nd floor exit doors lacking proper fire clearance as per the fire clearance dated 12/08/2022.

The applicant and administrator participated in a telephone call with the analyst to confirm understanding of facility operation, staff qualifications, program policies, and application document requirements. Component II of the evaluation was successfully completed with no deficiencies noted.