- Date
- 8/22/2025
- Report number
- 00423759-AP-375233
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about August 22, 2025, an Alleged Victim (AV) reported that Alleged Perpetrator 2 (AP2) entered AV’s room and engaged in non-consensual sexual contact, including kissing and forcing AV to perform oral sex. The incident reportedly occurred while AV was alone with AP2. Based on facility documentation and interviews, AV has a documented history of sexually inappropriate and threatening behavior toward both staff and residents. Upon AV's admission to the facility on August 21, 2025, facility completed a temporary care plan but did not include AV’s known behavioral history or need for two-person care requirement due to AV's known behavioral history. Staff interviewed during the investigation stated they were not informed of AV’s behavioral history and believed the two-person applied only to transfers, not all cares. The facility failed to document critical information regarding AV's prior behaviors in AV's temporary service plan. As a result, staff were not adequately informed of the need for enhanced supervision, increasing the risk of harm to AV. This failure resulted in staff being uninformed and unprepared to provide care for AV, thereby creating conditions that placed AV at risk of moderate harm, which is a violation of resident rights, is considered neglect of care, which constitutes abuse. AP2 allegedly sexually abused AV. An investigation inconclusively determined no abuse occurred.
- Sanction
- RCFCP25-01107 $450.00 fine assessed