- Date
- 9/9/2025
- Report number
- 00431964-AP-383794
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- 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 September 7, 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 9, 2025, facility staff responded to screaming coming from AV's room and found AV on the floor beside AV's bed, AV stated AV was trying to get up out of bed and fell to the floor. AV stated that both knees were in a lot of pain and staff found skin discoloration on AV's right-side scalp and a small laceration on right outer forearm. AV was sent to the emergency room for further evaluation. 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