Complaint Investigation Report

LPA received corroborating statements that R1 had been very unbalanced, required a lot of assistance and at times did not have or use her walker. R1's family indicated R1 was provided a walker and 3 canes for R1 to use. R1's medical assessment of 2/14/2020 did not reflect her change in condition and facilities observation of R1s non-ambulatory needs.

It was also disclosed residents room was observed with clothing items that did not belong to R1 and when R1 moved out of the facility, R1's family found several items of clothing that were missing and clothing that did not belong to R1, along with a wheelchair, that belonged to another resident and had the other residents name.

Based on statements received, corroborating evidence and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation for staff not meeting residents needs, resident sustained multiple falls with injury and staff did not safeguard residents personal belongings are both SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights and this report will be emailed to administrator.