complaint·October 3, 2023

Interviews conducted with facility staff, residents, and R1's family revealed that R1 had a medical condition that would cause R1 to try to ambulate on their own without asking for assistance from facility staff resulting in accidental falls. Interview with Staff #1 (S1) revealed that R1 would have delusional behaviors and although not present during R1s fall the fall was said to be the cause of R1 lowering bedrail and ambulating unassisted. Staff interviewed denied any wrongdoing. Review of medical records confirmed diagnosis of medical conditions that resulted in delusional behavior and psychosis episodes, which would cause R1 to try to ambulate without assistance. R1 was admitted to the facility on 7/13/2021, was hospitalized on 7/28/21 after R1 sustained a fall from trying to ambulate unassisted, and passed in the hospital on 8/21/21. During Investigator Spindola's investigation there was no supportive evidence that revealed facility staff neglected R1 and the injuries that R1 sustained were most likely due to the medical condition and trying to ambulate without assistance. Based on statements and interviews conducted with staff, clients, family, review of facility file records and medical records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held and a copy of this report was provided to Jen Jimenez.