- Date
- 6/10/2025
- Report number
- 00407093-AP-358157
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On June 10, 2025, at approximately 3:45 PM, the Alleged Victim (AV) was found unresponsive, lying face down on the floor of AV’s room with the cord from the window blinds wrapped around AV’s neck. Upon facility staff finding AV unresponsive, the facility's Emergency protocols were initiated, and AV was pronounced deceased at the scene. Facility documentation and interviews confirm that AV was identified as high risk for self-harm and suicide. AV’s care plan reflected this risk and included a history of suicidal ideation and self-injurious behavior. As a result, the care plan required enhanced oversight and specific interventions, including: 9 to 12 safety checks per shift, encouragement of sleep hygiene, prompting for restroom use, emotional support through structured interventions such as walks, music, social engagement, and family contact, monitoring of AV’s tolerance to stimuli, and immediate reporting of behavioral changes The Adult Protective Services (APS) Investigation #00407093 concluded that the facility failed to provide adequate administrative oversight to ensure that the monitoring protocols outlined in AV’s care plan were consistently followed. Specifically: required safety checks were not performed as documented, there was a lack of supervision despite AV’s known risk factors, and the facility failed to implement and follow AV’s care plan critical to AV’s safety. This failure directly contributed to the circumstances in which AV was found deceased. The facility’s failure to provide adequate supervision and care for AV, who was known to have serious mental health risks including suicidal ideation and self-injurious behavior constitutes a serious violation of resident rights., is considered neglect of care and constitutes serious neglect of care.
- Sanction
- RCFCP25-01209 $1500.00 fine assessed