- Date
- 12/30/2024
- Report number
- 00375347-AP-325790
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has history falls and fractures. AV service plan indicates fall risk, low fall risk, AV moved into the facility from skilled nursing due to a fall that had broken AV's hip in 3 locations, and AV is a known fall risk due to a history of falls. AV service plan indicates AV is independent with ambulation with or without assistive device. AV is able to determine the need for the use of h/h walker and may use it as s/he decides. AV is independent with transfers. On or about December 30. 2025, AV slipped in water on the floor of the facility dining area and fell. The water came from a water dispenser placed on a dining area countertop for residents to access fresh water. Prior to AV's fall, facility staff were aware that the water dispensers in use at the facility had no built-in means to prevent overflows, spills, or external condensation from migrating to the floor. As a result of the 12-30-24 fall, AV suffered a fractured right hip, severe pain, and required surgical repair. The facility failed to provide a safe environment, which is a violation of resident’s rights is neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00887 $375.00 fine assessed