Violation Details: 00431490-AP-383285

Records Request Print
Date
9/28/2025
Report number
00431490-AP-383285
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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 August 29, 2025, and September 28, 2025, AV had multiple falls with injury. AV's service plan, updated September 19, 2025, identifies AV as having a high fall risk with interventions for staff supervision and 2-person assist with transfers. AV had at least two additional falls after September 19, 2025, resulting in a fractured wrist. 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.
Sanction
RCFCP26-00556 $1500.00 fine assessed