- Date
- 9/25/2025
- Report number
- 00429401-AP-381100
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) and Witness 1 (W1) both present with impaired memory and limited decisional capacity to assess risk. They reside at AP1, which holds responsibility for developing and implementing service plans that address their care needs and ensure a safe living environment. AV is ambulatory and independently navigates the facility. AV exhibits occasional episodes of rapid walking and behavioral patterns that include entering other residents’ rooms. AV’s service plan dated approximately September 23, 2025, AP1 staff are expected to monitor AV’s behavior and provide redirection through snacks, walks, and one-on-one engagement as needed. AV’s general wandering does not require intervention; staff are specifically instructed to intervene during episodes of speed walking. W1 has a documented history of involvement in resident-to-resident altercations, including incidents involving AV. W1 is known to be particular about anyone going near W1's door, AP1 staff are expected to intervene and redirect anyone away from W1's door. On or about September 25, 2025, AV attempts to enter into W1's room; W1 physically attempted to remove AV from the door and struck AV in the face. The facility failure to appropriately service plan and implement reasonable interventions to address AV's wondering into other residents and keep residents away from W1 door resulted in a physical resident-to-resident altercation, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01436 $375.00 fine assessed