Violation Details: 00425378-AP-376931

Records Request Print
Date
9/6/2025
Report number
00425378-AP-376931
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
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(2)
External site: 411-054-0030(1)(e)(A)
External site: 411-054-036(2)(g) and 411-054-0070(1)
Findings
The Alleged Victim (AV) is a known fall risk and suffered 6 falls between August 14, 2025 and September 6, 2025. On or about September 6, 2025, AV suffered a fall where he/she was found on the floor, sustaining a laceration to his/her head and shoulder pain. AV was on 15 minute checks and interventions in place were for reminders to call for assistance and to use his/her assistive device when ambulating. There were not enough staff on overnight shifts to ensure the safety of all residents. The facility's failure to ensure proper staffing and properly care plan for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01438 $500.00 fine assessed