- Date
- 4/1/2025
- Report number
- 00392961-AP-343780
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a known history of falls. On or about March 27, 2025, Alleged Perpetrator 2 (AP2) directed a care conference for AV at the facility. AV’s service plan and changes in level of care were reviewed. Those present agreed to attempt to decrease 24-hour one-on-one care to 15-minute checks from 6:00am to 6:00pm. On or about April 1, 2025, at approximately 10:00am, AV was found on AV’s fall mat, AV tried to get up by AV’s self. Based on AP2’s position at the time of the incident, AP2 was responsible to make decisions about care for AV. AV’s family was “really advocating” for AV not to be on one-on-one. AP2 failed to provide a safe environment to AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00862 $1000.00 fine assessed