Complaint·May 30, 2024

A staff member (S4) claimed to have conducted a second reassessment on January 1, 2024 with R1’s RP present. LPA Moleski asked Swearingen for a copy of this second reassessment and written notifications sent regarding any increased care costs. Swearingen was unable to provide any such documentation in response to this request. Swearingen reached out multiple times requesting documentation from the prior management company in order to respond to LPA Moleski’s requests, but did not receive documentation to provide to LPA Moleski as described above. The department has determined the following as it relates to the allegation that staff did not provide sufficient notice of rate increase: Based on interviews and record review, sufficient written notice was not provided to R1’s RP after care costs were increased. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per HSC Section 1569.657(a). An exit interview was held with Swearingen. A copy of this report and appeal rights were left with Swearingen. The refunds were processed effective 2/12/24. LPA Moleski reviewed a statement from February 2024 indicating that credits were provided for resident care and for room and board costs for the month of January. In an interview, R1’s RP said that they had received the refunds. LPA Moleski reviewed an incident report regarding R1’s hospital visit on 12/7/23. The report stated that R1’s RP called a staff member to check on R1. The staff member said that R1 was pocketing food and refusing meals. R1’s RP said R1 should be taken to the emergency room. R1’s RP picked up R1 around 1 p.m. and took R1 to the hospital. R1 was diagnosed with failure to thrive and was sent back on 12/12/23 with palliative care. In an interview, R1’s RP was aware of R1’s hospitalization and said they had visited R1 while hospitalized. In an interview, R1’s RP said that staff were “force feeding” R1. When asked for clarification, R1’s RP said that staff continued to ask R1 if R1 wanted to eat, although R1 did not want to eat. LPA Moleski reviewed R1’s daily notes and observed in the record a pattern of limited food intake and many refusals of food and drink. Refusals are documented in the notes, and the authors of the notes indicated on several occasions the exact amounts of food which R1 did accept. None of the staff members interviewed had witnessed staff members force feeding R1 or any other residents, although several did remark that R1 often refused meals and/or ate very little food. Among the staff members interviewed, one staff member (S5) said that on one occasion, S5 came in for their shift and observed that R1 had not been changed by the previous shift. None of the other staff members interviewed had witnessed neglect or lack of care for the resident. Three other staff members (S5, S7, S9) who worked directly with R1 said that R1’s continence needs were met and had not witnessed any instances were R1 had been waiting for care or needing to be changed. Of the staff members interviewed, two (S5, S9) said there were temporarily previous issues with phone calls being transferred from the main line to the appropriate cottage. None of the other staff members interviews reported any issues with the phone systems. LPA Moleski has not had issues reaching someone at the facility by phone. [continued on 9099-C] The department has determined the following as it relates to the allegations that staff force fed a resident, that staff did not inform a resident’s authorized person of a change in condition, that staff did not meet a resident’s needs, that staff did not refund fees according to the resident’s admission agreement, and that staff did not answer the facility telephone. Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Swearingen.