- Date
- 10/11/2025
- Report number
- 00433388-AP-385318
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) resides in the Respondent’s facility and relies on facility staff for AV’s safety and assistance with daily care needs. AV has a history of falls and is identified as a high fall risk, including seven (7) falls prior to the incident on October 11, 2025. Despite this known risk, the facility failed to develop and implement sufficient interventions to mitigate risk to AV.
On or about October 11, 2025, facility staff found AV lying on AV's back in the middle of AV's room. AV experienced a fall, striking AV’s head on the floor. AV was transported to the hospital and diagnosed with multiple left rib fractures, a fracture of the left 5th metatarsal, and a fracture of the left radius. AV remained hospitalized from October 11 through October 13, 2025. Respondent failed to develop and implement appropriate interventions to address AV’s known fall risk. This constitutes abuse by neglect.
- Sanction
- RCFCP26-00433 $1500.00 fine assessed