complaint·January 29, 2025

**Report continued from 9099..... Allegation- Facility did not provide adequate supervision to resident resulting in resident sustaining severe injuries resulting in death. On August 28, 2024, at approximately 7:45 am, staff witnessed R1 in R2’s room standing over R2 while R2 was in bed. Interviews described witnessing R2 “covered in blood” and R1’s hands “covered in blood.” Staff quickly separated the two residents and 911 was called. R2 was taken to the hospital and diagnosed with significant facial trauma and swelling, tenderness and swelling to left eye, nasal bridge, and bilateral maxilla. Bleeding profusely from the left Nare and upper lip laceration approximately 0.5 cm. Medical records notated R2 passed away while at the hospital on September 3, 2024. The cause of death was listed as “Blunt Head Trauma.” Based on interviews conducted and documents reviewed, R1 had behaviors of wandering and going into other residents’ rooms during the day and night, however, interviews and documentation did not indicate R1 exhibited aggressive behaviors towards other residents. On August 28, 2024, it was reported that staff checked on R1 around 6:30 am. It was noted that R1 was awake but in their room. Staff then went on to finish their rounds, assisting other residents, and started cooking breakfast. Per facility policy and needs and service plans, both R1 and R2 were to be checked on every two hours by staff. Interviews reported that based on R1’s behaviors of wandering, staff were instructed to follow them and re-direct to the common areas. R1 at times showed aggression or agitation towards staff when they were showering or re-directing R1, but that aggression never resulted in physical violence. Based on interviews conducted and documents reviewed, the incident on August 28, 2024, wherein R2 was assaulted by R1 was an isolated incident. Although R2 sustained severe injuries while in care, neither R1 nor R2 required 1:1 care and supervision. Staff could not have predicted R1’s aggressive behavior would result on the assault of R2 therefore the allegation is UNSUBSTANTIATED. A finding that a complaint 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. Exit interview was conducted and a copy of this report was provided to the facility.