Violation Details: 00391586-AP-359616

Records Request Print
Date
3/25/2025
Report number
00391586-AP-359616
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide service
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
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. AV had a fall on April 20, 2025, and again on April 27, 2025, both when AV ambulating in common areas independently without any assistive devices. According to an investigation, despite AV's service plan still 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 fall risk and to ensure resident safety, placing AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP26-00069 $750.00 fine assessed