- Date
- 10/11/2025
- Report number
- 00432019-AP-384331
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) resides at the Respondent’s facility and relies on facility staff to provide the necessary services to maintain AV’s health and safety. AV has a known history of wandering into other residents’ rooms, including documented incidents in September 2025 and October 2025. AV’s service plan has interventions and requires staff to conduct checks on AV no fewer than six times per shift, to redirect AV if observed entering other residents’ rooms, and to ensure resident doors remain locked.
Facility staff failed to ensure resident doors were locked and did not complete required safety checks on AV. On or about October 11, 2025, AV entered W1’s room. W1 struck AV in the face with a shoe and told AV to leave. As a result, AV sustained red markings and two scratches on the face. AV was last observed at approximately 5:00 p.m. in the main hub before the incident, which occurred around 6:30 p.m., and W1’s door was not locked. Respondent failed to follow interventions. This constitutes abuse by neglect.
- Sanction
- RCFCP26-00289 $500.00 fine assessed