Violation Details: 00403549-AP-369464

Records Request Print Provider Details
Date
5/22/2025
Report number
00403549-AP-369464
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
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 his/her care. AV's care planned fall interventions were that AV requires 2-person assistance with all toileting and transfer needs. According to an investigation, on or about May 22, 2025, AV fell while being toileted and staff were too far away to intervene as AV fell, resulting in trauma to AV's arm and back and rib fractures requiring hospitalization. The facility failed to ensure the service plan was followed, which is a violation of resident’s rights, is neglect of care and constitutes abuse.
Sanction
RCFCP25-01200 $1125.00 fine assessed