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32 | (Continued from 9099)
On 1/10/2026 at approximately 9:30 pm, staff heard a sound and went to investigate. Upon entering Resident (R1) and (R2) room, it was discovered that R1 was lying in bed with blood on their face, forehead and top of head. R2 was sitting in a recliner fully dressed with a small amount of blood on their hand. 911 was called and R1 was taken to the hospital. Prior to the incident, both residents had dinner with their spouses who then helped get R1 and R2 ready for bed which was uneventful. Davis Police conducted an investigation and determined R2 inflicted the injury upon R1. R1 repeatedly said "assault," and "roommate" when asked by medical staff who assaulted them. R2 was interviewed but did not recall the event.
Interviews and record review found neither resident had a history of falls, aggressive behaviors, or any noted altercations (verbal or physical) with each other or any other individuals. R1 and R2 had been roommates since 8/25/25 with no history of aggression or incidents. Interviews with R1 and R2’s spouse showed that neither resident expressed any concerns regarding each other.
Based on interviews and record review, there is insufficient evidence to prove the facility had knowledge that R2 would become aggressive towards R1 causing injury.
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.
Report signed by Maria Rodriguez, RCFE Manager for Maria Burton, Administrator.
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