Violation Details: 00432609-AP-384466

Records Request Print
Date
10/6/2025
Report number
00432609-AP-384466
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is dependent on facility staff to meet some of his/her care needs and has a history of falls. According to an investigation, on or about October 3, 2025, AV returned from a hospital stay. Between October 3, 2025, and October 6, 2025, AV had three falls and was found on the floor. On October 6, 2025, AV was experiencing pain and was transported to the hospital and found to have fractures in both feet. AV's care plan did not identify effective interventions to address the falls. The facility failed to properly plan care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.