complaint·July 30, 2024

LPA conducted interviews with three (3) facility staff and (2) hospice staff who did not observe, have not observed, or have not previously heard of S1 handling R1 or the other residents in care in a rough manner. LPA conducted interviews with two (2) residents who denied being handled in a rough manner by S1 or other facility staff members. LPA conducted a records review of R1’s Physician Orders dated 06/17/2024 revealed R1 experiences confusion and/or is disoriented “sometimes”. R1’s Resident Appraisal dated 06/15/2024 states R1 “experiences episodes of confusion…”. LPA conducted an interview with R1 and determined R1 was not a reliable historian due to R1 stating the incident had occurred at a "well known hotel". S1 reported they did not handle R1 in a rough manner and had entered R1’s room multiple times throughout the night to conduct safety checks. Therefore based on interviews and records review the allegation “Staff handled resident in a rough manner” has been deemed Unsubstantiated at this time. Regarding the allegation “Staff force fed resident” it was reported S1 had forced food into S1’s mouth. Interview with two (2) residents denied hearing or observing S1 or other facility staff force feeding R1 or other residents in care. During the initial visit LPA observed staff preparing and serving lunch to the residents that did not indicate staff force feeding residents in care. Interview with three (3) staff reported they do not force feed residents and four (4) out of five (5) residents are capable of eating on their own without assistance. S1 reported they do not push food onto R1 and R1 does not need help with eating. Administrator Subotic reported R1 does not need assistance with eating. R1’s Physician Orders dated 06/17/2024 indicated R1 is capable of feeding self. R1’s Resident Appraisal dated 06/15/24 under “Services Needed” for “Help with eating (need for adaptive devices or assistance from another person)” is marked as “No”. LPA observed R1 eating a soup and a sandwich on their own with no staff assisting R1. LPA conducted an interview with R1 and determined R1 was not a reliable historian. Therefore based on observation, interviews, and records review the allegation “Staff force fed resident” has been deemed Unsubstantiated at this time. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted over the phone and a copy of this report was provided to Administrator Subotic. *This is an Amended Report*