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32 | Resident sustained broken bones due to staff neglect.
Interviews with staff and a review of medical records show that on 6/9/2026, R1 sustained an acute comminuted and displaced fracture of the distal left humerus with a butterfly fragment. R1 was not a documented fall risk and was scheduled for normal, frequent safety checks. Surveillance camera footage shows that on 6/9/2026 at approximately 0220 hours, staff checked on R1 in R1’s room; at approximately 0520 hours, staff found R1 on the ground. Staff called 911 and sought timely medical attention for R1 and appropriately reported the incident. There is insufficient evidence to conclude that staff failed to provide required supervision that resulted in R1 sustaining a great bodily injury. Based on the totality of the evidence obtained, the allegation that resident sustained broken bones due to staff neglect is UNSUBSTANTIATED.
Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be 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 with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
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