Complaint·November 13, 2025

In an interview, R1’s responsible party (R1’s RP) said that facility administrator Sangeetha Vipulananda called them after R1 fell on 7/9/25, and was told that R1 was fine and not complaining of pain. R1’s RP said they spoke with R1 over the phone the next day, 7/10/25, and R1 began complaining of pain. R1’s RP requested staff to have R1 sent to the hospital on 7/10/25. In an interview, a staff member on duty at the time of R1’s fall (S1) said that they observed another resident (R2) enter into R1’s room on the morning of 7/9/25. When S1 redirected R2 from R1’s room, S1 observed R1 on the floor near their bed. According to S1, R1 said that they became scared when R2 entered their room, and fell out of bed as a result. S1 said they assisted R1 up and conducted a body check, but observed no obvious signs of injury. S1 provided CCLD with a photograph taken of R1’s back, which appeared grossly unremarkable. According to S1, R1 did not complain of pain throughout 7/9/25 and 7/10/25. A second staff member on duty at the time did not appear for a scheduled interview with CCLD. In an interview, R1 was able to recall their fall. “I was asleep and rolled out of bed,” R1 said. R1 did not remember being in pain after their fall. Medical records obtained by CCLD indicate that R1 told first responders who arrived at the facility on 7/10/25 that they did not initially experience pain after their fall, but they were experiencing pain when trying to move their leg on 7/10/25. R2 was not able to recall R1’s fall and did not have pertinent information to share with CCLD. The department has determined the following as it relates to the allegations that a resident sustained a fracture while in care due to staff neglect, and that staff did not seek medical attention for a resident in a timely manner: Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with McCoy.