complaint·October 20, 2021

Throughout the course of the investigation, CCL conducted interviews and reviewed documents. Interviews were conducted with residents R2-R5, Administrator, and R1’s Responsible Party (RP). Through interviews conducted, CCL learned that R1 would sometimes help himself to his room/bathroom without asking for assistance. On this day it was immediately following lunch time, and staff was working in the kitchen/dining area. R1 was sitting in front of television in living room when he decided to go to his bedroom without notifying the staff. His bedroom is around the corner from the living room, and before staff noticed he had moved, S2 heard his fall. Staff found R1 on the floor and asked him to stay on the floor while she called paramedics. Paramedics arrived shortly thereafter (within 10-20 minutes). CCL was informed that staffing was adequate the day of the fall, and R1 was regularly monitored by caretakers. CCL was unable to determine that R1’s fall was due to lack of care and supervision. Through interviews conducted, documents reviewed, and facility visits performed; CCL finds the allegation of Facility’s lack of care and supervision resulted in resident’s fall to be UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. A copy of this report was left at facility.