Violation Details: 00401602-AP-352496

Records Request Print
Date
5/13/2025
Report number
00401602-AP-352496
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
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) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about May 13, 2025, AV fell after walking to the dining room and trying to sit on a chair, hitting their head on a piece of furniture. AV's service planned interventions were for staff to provide escorts to meals and for staff to monitor and re-direct AV as needed related to lower extremity weakness. At the time of the incident, AV did not have an escort to direct or assist as specified in the service plan, resulting in a fall with injury. The facility failed to follow the care plan for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
RCFCP26-00123 $500.00 fine assessed