- Date
- 10/13/2025
- Report number
- 00432357-AP-384201
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) and Witness 1 (W1) reside in the Respondent’s facility and rely on facility staff for their safety and assistance with daily care needs. AV has a documented history of visual hallucinations, anxiety, and episodes of frustration. W1 has a history of irritability and becoming overwhelmed by loud noises and crowded environments, as well as a documented history of resident-to-resident altercations. This includes an incident on or about October 10, 2025, in which W1 threw a coffee cup at another resident in the dining room.
The facility failed to implement and follow the interventions in place to mitigate risk to AV, which contributed to a resident-to-resident altercation between AV and W1. On October 13, 2025, AV was yelling in the dining room. In response, W1 threw W1’s dinner plate on AV and then held the plate upside down over AV’s head, smearing food onto AV. The Respondent failed to follow implemented interventions. This constitutes abuse.
- Sanction
- RCFCP26-00432 $375.00 fine assessed