Violation Details: 00421427-AP-372874

Date
8/18/2025
Report number
00421427-AP-372874
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide safe environment
Result
Substantiated
Findings
The Alleged Victim (AV) is a known fall risk and has suffered 5 falls between July 29, 2025 and August 18, 2025. On or about August 18, 2025, AV was found lying on the floor in his/her room with no feeling in his/her feet. It appeared that AV tried to use the restroom without his/her assistive device. AV was transferred to the hospital and diagnosed with a fractured toe and a bruise on his/her head. AV was last seen 15 minutes prior to the fall, and requires 1 person assist with transfers and cueing with ambulation. The facility's failure to ensure safety and supervision of AV while transferring and ambulating is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01371 $375.00 fine assessed