- Date
- 3/25/2025
- Report number
- 00391586-AP-342401
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for care and is a high fall risk. AV is care planned for falls to be monitored, to ensure AV is wearing proper footwear, to encourage AV to use a walker and wheelchair, and is also care planned as independent with transfers and ambulation. On or about March 25, 2025, AV reported they had a leg wound and needed assistance, claiming they bumped their leg on something. Then on April 12, 2025, AV had two separate falls, when ambulating in common areas independently without any assistive devices. According to an investigation, AV had been declining recently and was a higher fall risk, possibly due to new medications, and despite AV's service plan indicating to encourage AV to use their walker or wheelchair, AV did not have a walker or wheelchair to use. The facility failed to provide services, to include properly care planning and/or implementing interventions to mitigate AV’s declining health and to ensure resident safety, resulting in physical injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP26-00069 $750.00 fine assessed