- Date
- 8/27/2025
- Report number
- 00428326-AP-379986
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about August 27, 2025, AV was found on the ground in the courtyard and had sustained a skin tear. Between July 28, 2025, and September 24, 2025, AV had at least five falls. AV's July 14, 2025, service planned interventions were for staff to ensure AV was wearing non-skid footwear and keeping assistive devices and personal possessions in reach. Following a fall on September 24, 2025, AV was sent to the emergency room when s/he was showing signs of severe pain and was unable to walk. The facility did not develop or implement any known changes to AV's care plan following the falls. The facility failed to develop fall interventions to address AV’s fall risk, resulting in injury and evaluation at the emergency department. The facility failed to plan care for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- RCFCP26-00008 $1500.00 fine assessed