- Date
- 8/1/2025
- Report number
- 00417884-AP-369213
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Both the Alleged Victim (AV) and Witness 1 (W1) have documented cognitive decline. AV and W1 have a history of resident-to-resident altercations—both with each other and with other residents. W1 is known to become triggered when other residents enter or pass through W1’s personal space, including residents walking past W1’s doorway. AV is known to ambulate frequently throughout the facility when awake. Following an altercation between AV and W1 on or about July 26, 2025, the following interventions were implemented: staff are to ensure AV remains in a common area away from W1’s apartment, staff are to redirect AV if observed walking near or past W1’s room. Despite these interventions, on or about August 1, 2025, AV was walking down the hallway when W1, who was standing in the doorway of their room, reached out and struck AV’s right shoulder with the side of a closed fist. The facility failed to maintain a safe environment, provide adequate oversight, and follow the interventions in place for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01118 $375.00 fine assessed