Complaint Investigation Report

LPA reviewed C1's Physician's report dated December 10, 2013 which had no diagnosis listed. LPA reviewed C1's needs and service plan dated January 1, 2024. C1's diagnosis included; schizophrenia, mood disorder and Diabetes (controlled with diet and medication) LPA reviewed C1's medication administration report (MAR's) for the months of June and July 2025. MAR's indicated that C1 did not take C1's medications on the following dates; June 10-11, June 17-18, June 24-25. Facility staff were unable to determine if the missed medications were due to client refusal or due to client being away from the facility.

LPA interviewed C1 at the facility. C1 spoke to LPA hunched over. C1 appeared weak and sickly. C1 stated that prior to calling 911 C1 had not eaten for 3-4 months. C1 stated that C1 does not like "chicken and rice" and that is what they serve every day. C1 stated that C1 purchases their own snacks but C1 has not had much of an appetite. C1 stated that they have told all of the staff and although they stated they would change the menu, it has remained the same. C1 stated that C1 has only missed taking their medications "a couple of times" a month. C1 stated that they had suicidal ideations for a week, on and off, prior to going to the hospital. C1 stated that C1 returned from the hospital six days ago and and has not eaten, with the exception of a bowl of cereal which C1 could not finish. C1 stated that they have the following medical conditions; diabetes, high cholesterol and high blood pressure. C1 stated that C1 has not checked their blood sugar and does not know what it currently is.

LPA interviewed Client 2 (C2) at the facility. C2 stated that C1 has not been eating for a month. C2 stated that if C1 does not like the food they will not eat it. C2 stated that facility staff are aware that C1 has not been eating. C2 stated that staff have not helped C1. C2 stated that C2 purchased several snacks for C1 but C1 has not touched them. C2 stated that the facility serves boiled chicken and rice daily. C2 stated that when emergency services arrived at the facility for C1, C1 was weak and was taken to the hospital. Client 3 (C3) and Client 4 (C4) corroborated C1's statement that the facility serves chicken and rice on a daily basis.

LPA interviewed Outside Source (OS) who stated that on the date that emergency services arrived at the facility, EMT waited 5-10 minutes before entering the gated facility since their were no staff members present. OS stated that EMT's entered the facility after C1 "flagged them down" and told them to enter the facility. OS stated that C1 advised the EMT that C1 had resided at the facility for 10-15 years and has eaten the same two meals for their entire stay. C1 stated that C1 had suicidal ideations and had not eaten or slept for three weeks. C1 was taken to the hospital with a fever over 100 degrees.