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32 | INVESTIGATION REVEALED THE FOLLOWING:
Allegation #1: Lack of staff supervision resulting in residents engaging in a physical altercation.
The complaint alleges that a lack of supervision led to a physical altercation among residents. It has been reported that Resident #1 (R1) and Resident #2 (R2) were involved in an incident that resulted in (R1) being admitted to the hospital with a closed ankle fracture. Further reports indicate that the altercation occurred in (R1's) room after (R2) entered, resulting in a confrontation. No additional information regarding the allegation has been provided.
On April 25, 2026, between 9:45 AM and 11:59 AM, the Department interviewed resident members identified as Resident #2 through Resident #9 (R2-R9). Eight (8) out of the (8) were unable to support this claim. (R2-R9) were all complimentary of the staff and expressed that they received adequate care, support and supervision in a responsive manner. (R2) could not recall the incident that occurred on June 08, 2025, with (R1) and denies having any physical altercations. (R2) stated to be on a friendly relationship with (R1).
Resident #1 (R1) was not available for an interview as the resident is currently being treated at Santa Fe Post Acute and did not return calls.
On April 25, 2026, between 8:40 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not validate this allegation. Staff members (S1-S5) expressed care and supervision are priority for all staff. According to (S1-S5), there have been no prior verbal or physical altercations between Residents #1 (R1) and #2 (R2). Both residents are diagnosed with Major Neurocognitive Disorder (NCD) and exhibit behaviors associated with this condition. However, neither requires one-on-one care.
(S5), who was present during the incident, reported that two other staff members, along with (R1) and (R2), immediately responded when they heard yelling and noises coming from (R1's) room. (S5) explained that (R2) wandered into (R1's) room, mistakenly thinking it was (R2’s) own room, and sought to use the bathroom. During this encounter, a verbal and physical altercation occurred, wherein (R1) grabbed (R2) by the arm, prompting (R2) to push (R1), who then fell to the floor. Following the incident, (R1) complained of leg pain and was taken to the hospital.
(S1-S2) disputed claims of a lack of supervision, emphasizing that the facility has adequate staffing, trained personnel, immediate communication via walkie-talkies, and surveillance cameras in place. (S1) detailed the staffing for different shifts: the morning (AM) shift consists of five caregivers, two med-techs, and one nurse; the afternoon (PM) shift includes five caregivers, two med-techs, and one nurse; while the evening (NOC) shift has four caregivers and one med-tech.
(Evaluation Report continues LIC 9099-C)
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