Violation Details: 00427502-AP-379240

Date
9/17/2025
Report number
00427502-AP-379240
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Findings
Alleged Victim (AV) lives at Respondent’s facility. AV has history of falls, including an incident that occurred in August 2025, resulting in injury and requiring a two-week hospital stay. AV's service plan reflects that AV is a fall risk, and interventions in place, facility staff to perform safety checks on AV 2 times per shift (every 4 hours), AV uses fronted wheeled walker, and requires one-person assistance with ambulating, transfers, bathing, dressing, personal hygiene and toileting. On or about September 17, 2025, facility staff found AV lying on h/h back on the floor in the bathroom, with shower on. AV has a lump on back of head, and left shoulder pain. AV transported to emergency room for evaluation. Respondent failed to provide a safe environment, and follow AVs service plan, which constitutes abuse by neglect.
Sanction
RCFCP26-00222 $375.00 fine assessed