Violation Details: 00431115-AP-382897

Records Request Print
Date
10/7/2025
Report number
00431115-AP-382897
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 24, 2025, and October 7, 2025. On or about October 7, 2025, AV suffered a fall while trying to transfer out of his/her bed, where he/she was found on the floor, sustaining a skin tear to his/her elbow. AV was on frequent checks and interventions in place were for reminders to call for assistance and to use his/her assistive device when ambulating. There was not appropriate staffing during overnight shifts to ensure the safety of all residents.
Sanction
RCFCP25-01464 $375.00 fine assessed