- Date
- 9/26/2025
- Report number
- 00429621-AP-381335
- 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. W1 is ambulatory and independently navigates the facility. W1 exhibits behavioral patterns that include entering other residents’ rooms. W1’s service plan dated approximately September 23, 2025, AP1 staff are expected to monitor W1’s behavior and provide redirection through snacks, walks, and one-on-one engagement as needed. W1’s general wandering does not require intervention. AV has a documented history of involvement in resident-to-resident altercations, including incidents involving W1. AV is known to be particular about anyone going near AV's door, AP1 staff are expected to intervene and redirect anyone away from AV's door. On or about September 25, 2025, W1 attempts to enter into AV's room; AV physically attempts to remove W1 from the door and struck W1 in the face. W1 shoved AV, causing AV to stumble and fall backwards hitting AV's head resulting in a large lump on AV's head, requiring emergency services at the hospital. The facility failure to appropriately service plan and implement reasonable interventions to address W1's wondering into other resident rooms and keep residents away from AV's door resulted in a physical resident-to-resident altercation, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01444 $375.00 fine assessed