Violation Details: 00423087-AP-374569

Records Request Print
Date
8/26/2025
Report number
00423087-AP-374569
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(1)(a) and (b)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) lives at Respondent’s facility. AV has a history of falls, including an incident that occurred on August 17, 2025. AV's service plan reflects that AV is independent with ambulation, and to prevent falls for AV facility staff should ensure AV is wearing proper footwear, non-slip, well-fitting shoes or slippers with good support at all times. However, the facility staff failed to follow the service plan and ensure AV was wearing proper footwear. On August 26, 2025, AV was walking with one black slide shoe and a sock on the other foot. AV got up and walked across the room, stumbled and fell landing on h/h left side. As a result of the fall AV was sent to the hospital and diagnosed with a fracture of the left arm. The respondent staff failed to follow AV's service plan and fall preventions.
Sanction
RCFCP25-01468 $1500.00 fine assessed