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32 | Allegation: Staff did not provide adequate supervision, resulting in a resident in care sustaining fractures.
It is alleged that facility staff did not respond in a timely manner when a resident in care called for help. On 03/02/26 and 05/01/26 The Department conducted interviews with R1-R10 regarding the allegation above. During interview with R1, R1 confirmed being assaulted but could not provide detailed information regarding the above allegation, however, R1 believes it took 5 minutes for staff to respond and assist. Additionally, R1 states feeling safe to return to the facility for care. During interview with R2, R2 confirmed the assault however R2 did not provide any information regarding the allegation above. During interviews with R3-R10, 7 of the 8 residents interviewed denied the allegation above and reported that assistance from staff is provided when requested, 1 of the 8 residents interviewed reported being independent and assistance from staff is not required. Furthermore, 6 of the 8 residents interviewed on 05/01/26 indicated that staff response time is within minutes, 1 of the 8 residents reported staff response time can take up to an hour, 1 of the 8 residents interviewed reported being unaware as staff assistance is not required. On 03/02/26 The Department conducted interviews with S1-S3 regarding the allegation above. 3 of 3 staff interviewed denied the allegation above. Per 2 of the 3 staff interviewed, they were on shift the night of the incident and assisted as soon as they were notified of the situation. Per 3 of 3 staff interviewed, there was no history of violence between R1 and R2 nor individually with other residents in care. On 03/12/26 The Department conducted a review of medical records from Long Beach Memorial Hospital date: 2/15/2025 which indicated that R1 was admitted to Long Beach Memorial Hospital with a diagnosis of: Assault, Closed non displaced fracture of head of left radius sequela, and Closed fracture of multiple ribs of left side, initial encounter. On 03/12/2026 The Department conducted a review of medication compliance list for R2, per medication administration record R2 had been refusing to medications from 02/6/26- 02/13/26. Upon review it is unclear if the refusal of these medications during this period contributed the assault/battery that occurred between R1 and R2.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
Exit interview conducted, and a copy of this report was not provided.
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