Complaint·February 4, 2022

Allegation: " Neglect and lack of supervision resulting in fracture." Based on record review and interviews conducted the findings indicate that on January 27, 2022 at approximately 9:00 AM, 98 year-old resident (R1) had an un-witnessed fall in the room. It is unknown how long the resident was on the floor. Staff (S4) found the resident on the floor next to the night stand. A body check was conducted, and at first the resident did not report major pain or discomfort. Caregiver checked on the resident approximately 2 hours later, and the resident then reported knee pain and discomfort. The resident was then transported to Norwalk Community Hospital approximately 4 hours later. Resident (R1) sustained a knee fracture and is presently recuperating at a Skilled Nursing Facility. Staff stated R1 is overall independent, uses a walker, and requires minimal assistance. However, per Individual Service Plan (ISP) resident (R1) is at fall risk. Staff reported caregivers perform room checks every 2 hours. All staff interviewed denied negligence or lack of supervision in regards to R1's fall incident. Three (3) out of nine (9) residents stated staff do not perform regular room checks and there is not enough staff supervision. Family has not had any concerns with resident (R1's) care. There is insufficient evidence to support the allegation. Based on record review and interviews conducted the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Assistant Administrator Cynthia Flores. A copy of the report was issued.