complaint·October 30, 2025

It was alleged that due to lack of supervision, Resident #1 (R1) threw an object, possibly a telephone, at Resident #2 (R2) causing R2 to sustain a C1 fracture. Staff and resident interviews revealed that R1 did throw an object at R2 resulting in injury. The Woodland Hills North Regional Office received an incident report and SOC 341 from the facility on 08/22/2025 stating that on 08/21/2025, R1 threw a hard object at the back of R2’s head in the dining room and R2 reported pain in the area. R2 was assessed and admitted to the hospital. Record review and interview revealed that R2 had a previous C1 fracture and it is unknown if the incident caused a new fracture or aggravated the pre-existing fracture. LPA interviewed R1, R2, and R1’s responsible party and no evidence of malicious intent was noted. R1 and R2 stated there is no lack of care and supervision being provided. Following the incident on 08/21/2025, R1 was seen by their physician and received new medication orders. Interviews with staff and R1’s responsible party noted that the medication change has been effective in addressing R1’s behavior. Interviews stated that R1 did not have a history of aggressive behaviors, and no similar incidents have occurred as of today’s visit. Interviews confirmed that two (2) kitchen staff members were nearby during the incident and R2 received medical attention immediately upon notifying staff. LPA reviewed records and observed that R1’s assessment signed and dated on 03/23/2025 document that R1 does not need supervision to perform activities of daily living (ADL), behavior management, or escorting and that R1 is oriented. R1’s physician’s report signed and dated on 07/07/2025 document that R1 exhibits confusion and is disoriented inconsistently and does not have aggressive or inappropriate behaviors. R2’s assessment signed and dated on 02/06/2025 documents that R2 needs some ADL and transfer assistance but does not need escorting and is oriented. R1 and R2’s care plans do not include 24/7 supervision or supervision in common areas. As R1 and R2 do not require supervision in common areas and the facility made a quick and effective response in addressing R1’s behavior, there is not sufficient evidence to support a lack of supervision. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Due to lack of supervision, resident injured another resident while in care” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.