Complaint Investigation Report

The investigation revealed the following:

Allegation: Facility staff are not providing adequate food service to clients in care.

It is being alleged that clients in care receive the same meals every day. On 04/09/25 from 10 am-11:22 am LPA conducted interviews with clients C2-C5, 1 of 4 clients interviewed confirmed the allegation above reported they receive rice with every meal every day, 1 client interviewed reported going out for meals daily, 2 of 4 clients interviewed denied the allegation and reported having no issue with the meals being served. On 04/09/25 from 11:22 am-11:55 am LPA conducted interview with C1, C1 did not not provide an answer when asked about the allegation above; however C1 spoke about the variety of food provided at the facility that is not to C1's liking. On 04/17/25 LPA conducted a tour of the facility kitchen and pantry, LPA observed the pantry to have a variety of food selection, the kitchen refrigerator was stocked with a variety of fruits, proteins, and vegetables. On 04/17/25 LPA conducted a review of menus for the months of March 2025-April 2025, LPA observed breakfast, lunch, and dinner meals to be different every day. On 04/09/25 from 12 pm-12:40 pm LPA conducted interview with L1 regarding the allegation above, L1 denied the allegation above and stated that the kitchen staff have actually gotten compliments about the food from the newer clients coming in. On 04/17/25 from 1 pm-2 pm LPA conducted interview with S1-S3, 3 of 3 staff interviewed denied the allegation above about reported clients have different meals every day.

Allegation: Facility staff did not provide resident medication as prescribed.

It is being alleged that client in care did not receive blood pressure medication.

On 04/09/25 from 10 am-11:22 am LPA conducted interviews with clients C2-C5, 4 of 4 clients interviewed denied the allegation above and reported receiving their medications everyday. On 04/09/25 from 11:22 am-11:55 am LPA conducted interview with C1, C1 confirmed the allegation above and reported that staff have not given C2 a blood pressure machine. On 04/09/25 from 12 pm-12:40 pm LPA conducted interview with L1 regarding the allegation above, L1 denied the allegation above and reported medications are administered as prescribed. On 04/17/25 from 1pm-2 pm LPA conducted interview with S1-S3, 2 of 3 staff interviewed denied the allegation above and reported staff do not refuse to to administer medications to clients in care. 1 of 3 staff interviewed reported they do not have any knowledge regarding the allegation above as they do not assist with medication administration. On 04/17/25 LPA conducted medication review for C1, LPA observed the MAR and physical medications to match. Per MAR C1 is receiving all medications as prescribed. On 04/17/25 LPA conducted a review of physicians report dated 9/19/24, there is no indication that C1 requires to have to blood pressure taken before medication is administered.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report was provided to Licensee.