- Date
- 7/21/2025
- Report number
- 00415570-AP-366859
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- On or about July 21, 2025, at approximately 4:30a.m., Alleged Victim (AV) experienced an unwitnessed fall resulting in a significant injury. Facility documentation and interviews confirm that AV was admitted on June 29, 2025, and was identified at the time of admission as being at high risk for falls. However, AV’s care plan dated June 29, 2025, lacked sufficient fall prevention strategies or interventions to mitigate this known risk. As a result of this failure, AV sustained fractures and required hospitalization. The facility's lack of appropriate oversight and care planning regarding AV's known fall risk, caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01191 $1125.00 fine assessed