- Date
- 10/11/2025
- Report number
- 00433388-AP-410095
- 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 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 a fall on October 11, 2025, that hospitalized AV from October 11 through October 13, 2025, with multiple fractures. Av's service plan reflects keeping AV's cellphone on nightstand next to bed so AV does not to get up for it, and place walker next to AV's bed.
Despite AV's known fall risk, the facility staff failed to follow AV service plan and interventions to mitigate risk to AV. On or about October 15, 2025, AV was trying to get out of bed to look for AV's phone & purse. Facility staff found AV lying on the floor next to AV's bed, AV’s wheelchair and walker were in front of h/h dresser not by AV’s bed. Respondent failed to follow AV's service plan and interventions. This constitutes abuse by neglect
- Sanction
- RCFCP26-00433 $1500.00 fine assessed