Violation Details: 00431468-AP-383261

Records Request Print
Date
7/26/2025
Report number
00431468-AP-383261
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
411-054-0036(2)(g)
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, between June 13, 2025, and August 14, 2025, AV had multiple falls with injury. AV's service plan, updated July 14, 2025, identifies AV as having a high fall risk with interventions for staff supervision, a fall mat and positioning with a pillow in bed. AV had at least two additional falls after July 14, 2025. The facility did not develop, implement or communicate to staff 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. The facility failed to properly plan care for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
RCFCP26-00554 $500.00 fine assessed