Violation Details: 00395878-AP-346567

Date
4/16/2025
Report number
00395878-AP-346567
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 their care and has a history of falls. AV is known to get up and down several times throughout the night and forgets that AV is not as independent with transfers as AV used to be. AV is care planned for hourly checks. According to an investigation, on or about April 16, 2025, AV was found on the floor with AV’s back leaning against AV’s wheelchair, resulting in shoulder pain. The facility failed to provide appropriate services, related to care planning to implement appropriate interventions to mitigate the risk of injury due to AV's increase in falls and following the care plan for hourly checks. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01120 $375.00 fine assessed