Follow-up·July 19, 2022

On 5/14/2022, the facility reported a serious incident concerning resident #1 (R1) who was not in the apartment and later was found in a private balcony four stories under his/her apartment, unresponsive, in a seating position with head injury. Licensing Program Analyst (LPA) Murial Han made a case management visit on 5/20/22 regarding the incident and initiated an investigation. On 7/19/2022, LPA conducted a follow-up visit to deliver the findings of the investigation. During the investigation the Department collected documentation and conducted interviews. The coroner reported to the facility that the incident was due to self-inflicted harm. Staff reported that R1 was checked on a few hours prior to the incident, and did not observe anything unusual. In addition, R1 has never shown any behaviors of self-harm. Based on interviews conducted and information from the coroner's office, there is no preponderance evidence of lack of supervision and neglect from the facility, therefore, this incident is deemed to be unfounded. No deficiency cited. This report is discussed and reviewed with the administrator. A copy is provided.