Violation Details: 00431964-AP-383791

Records Request Print
Date
9/3/2025
Report number
00431964-AP-383791
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)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)(a) and (b)
External site: 411-054-0030(1)(e)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) resides in the Respondent’s facility and depends on the facility staff to provide appropriate supervision and care. AV has a documented history of falls, including a fall on August 23, 2025. According to AV’s service plan, AV requires standby assistance with bathing, dressing, toileting, transfers, and supervision with ambulation. Despite this, the respondent failed to develop adequate interventions to mitigate AV’s ongoing fall risk. On or about September 3, 2025, facility staff found AV bedside on the floor bleeding from the back of the head, AV was transported to the hospital emergency room with an inch long laceration. The Respondent failed to develop and implement appropriate interventions to address AV’s continued fall risk. This failure constitutes abuse by neglect.
Sanction
RCFCP26-00379 $500.00 fine assessed