Complaint Investigation Report

Regarding the allegation: Staff are mismanaging resident's medication. It was alleged that staff had mismanaged R1’s medication. To investigate the allegation, LPA conducted interviews with one (1) resident and five (5) staff members. LPA’s interview with R1 revealed that on multiple occasions, staff have not distributed their medication on time, have mixed other residents’ medication with their Medication Administrator Records (MARs) and have not refilled their medication in a timely manner. LPA’s interview with all five (5) staff members confirmed that R1’s medication is distributed on time (there is a two (2) hour window for medication pass), recorded correctly on the Medication Administration Records (MARs) and refilled in a proper time frame. All five (5) staff members confirmed that resident’s medications are administered as prescribed. However, during LPA’s record review of R1’s MARs, LPA observed on 1/15/2026 it was shown R1 was given one of their prescribed medications by S5. When LPA conducted a record review of R1’s medication, LPA observed said medication could not be found. Upon further review it was revealed that the medication was not yet available. LPA’s interview with S5 revealed they had mistakenly marked medication as taken and were planning on correcting it on the MARS. Additionally, LPA’s review of R1’s medication, LPA observed two (2) medications to be missing resulting in S1 having to go to the medication room to find said medication. S1 was able to locate one (1) of the two (2) medications during LPA’s visit.

Based on interviews, record review and observations there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Regarding the allegation: Staff did not give resident a 60 day notice for increase in rent. It was alleged that staff did not provide R1 with a 60-day notice of rent increase. To investigate the allegation, LPA conducted interviews with one (1) resident and two (2) staff members. LPA’s interview with S2 revealed that R1 is under the program of Assisted Living Waiver (ALW) and receives Social Security Administration (SSA). LPA’s interview with S2 revealed that R1’s rent is paid directly to the facility by the third-party provider (SSA). S2 revealed that R1’s rent increase occurs annually which is determined by SSA and not them. S2 revealed that SSA will send notification to all residents who are SSA recipients, and the facility themselves have posted the announcement on the community bulletin.