Complaint Investigation Report

The other resident interviewed (Resident 3) reported that they were unsure of what medications they were currently prescribed and could not tell the LPA how many different medications they were taking. A review of R1’s medications and MAR for April 2026 shows R1 received their 13 routine medications as prescribed except when R1 was not at the facility. R1 is prescribed 5 PRN medications which they did not request (R1 verified this information). R1 attends dialysis three times per week, which accounts for the discrepancy in the MAR. Five out of five staff reported medication is always administered as prescribed. LPA reviewed the medications and MAR (April 2026) for Resident 2, Resident 3, Resident 4 and Resident 5, no discrepancies observed.

Regarding the allegation that Staff does not follow resident’s prescribed diet , the following has been concluded: A review of records shows R1’s Physician’s report dated April 7, 2026, that R1 is prescribed a low carbohydrate diabetic diet. Staff 1 reported that R1 has been prescribed a renal diet, but there is no documentation to support this report. Staff 1 reported R1 does not follow their prescribed diet and eats whatever they want. Staff 1 reported that they have attempted to talk to R1 about their diet, but R1 will not discuss it with them. R1 is on dialysis three times a week. R1 reported they are not on a renal diet; they are on a diabetic diet. Staff 1 reported that many of the residents at the facility are diabetic, so the facility menu is based on a low carbohydrate diabetic diet. Five out of five staff interviewed confirmed that R1 refuses to eat food served by the facility due to personal preferences. R1 reported they do not like the food at the facility and it is bland and usually served cold. R1 reported they prefer to eat out and eat what they want.

Regarding the allegation Facility is not clean , the following has been concluded: It was reported that R1’s bathroom was not clean and had blood stains on the sink. Four out of the five residents interviewed expressed their satisfaction with the facility staff cleaning the rooms and bathrooms on a regular basis. One resident stated that their roommate was not always neat but denied that it was due to staff negligence because they stated their bathroom gets cleaned regularly. R1 reported that their room is clean but wanted help cleaning their wheelchair. R1 reported that their bathroom is clean. Four out of Four staff reported cleaning is done everyday in the facility and rooms are checked and cleaned when needed. LPA observed during the initial 10-day visit the facility and resident rooms and bathrooms were clean. LPA observed some residents were disorganized, but their rooms were clean.