Complaint·November 14, 2024

Records also revealed at the time of admission R1 was continent and able to manage all their own daily living skills except they required minimal assistance with bathing and grooming reminders. Further review of R1’s resident records revealed less than a month after R1's admission on March 19, 2020, they started to undergo changes in health conditions. In addition, R1 started to display behaviors of concern. A review of facility records dated February 21, 2021, revealed R1’s care needs had increased to requiring a 1 to 2 person assist with ADLs, was non-ambulatory, and required incontinence care. Facility staff conducted a re-appraisal and updated R1's care plan based on new doctor’s orders. However, on March 21, 2021, R1 was given a 30-day eviction notice for several acts of verbal and physical aggressive behaviors toward staff and other residents in care. Records of R1’s behavior outbursts were dated between September 14, 2020, and February 2, 2021, and included yelling profanities during the day and throughout the night scaring and disrupting other resident’s sleep, and conducting inappropriate acts that were sexual in nature. A facility records review revealed it was clearly defined that these behaviors were breaking the rules of facility conduct per contractual agreement. In addition, outside source records revealed on May 12, 2021, R1 was still residing at the facility and R1’s Primary Care Physician (PCP) had submitted an order for R1 to be relocated to a higher level of care, and they were transferred to a post-acute facility. Regarding facility staff not meeting R1’s needs, as mentioned above, R1’s PCP submitted an order for R1 to be transferred due to needing a higher level of care. In addition, a facility records review and interviews conducted with facility staff revealed R1 would refuse assistance by facility staff and would become verbally and physically aggressive. Lastly, it was alleged medications were observed unlocked and cleaning supplies were accessible to residents in care. Staff interviews revealed all medications are kept in locked med-carts, and cleaning supplies were kept in locked storage. During facility tours, LPA observed medications and toxins to be locked and inaccessible to residents in care. (See LIC 811 for confidential name). Due to lack of corroborating evidence, the findings regarding the above allegations were established to be unsubstantiated. This finding means although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. LPA Correia conducted an exit interview with RSD Pagala who was advised a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058) will be provided and signature on this report acknowledges receipt of the rights.