- Date
- 10/28/2025
- Report number
- 00435585-AP-387719
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about October 28, 2025, a physical altercation occurred between Witness 1 (W1) and the Alleged Victim (AV), both residents of the facility. During this incident, W1 initiated physical aggression toward AV, resulting in unreasonable discomfort and a loss of personal dignity for AV. Documentation and interviews revealed that the facility failed to appropriately monitor W1 in accordance with his/her known behavioral history and mental health needs. W1 was admitted to the facility on or about September 3, 2025, from a mental health placement where he/she had been assessed as stable and capable of thriving in a long-term care setting. Although W1 was generally described as pleasant and happy by facility care staff, the staff noted a marked change in the week leading up to the incident. W1 began exhibiting significant emotional and behavioral changes, including fear, paranoia, delusional thinking, and sadness. The investigation determined that the facility did not adequately address or mitigate a lapse in W1’s mental health medications. This failure contributed to W1’s sudden destabilization and the behavioral escalation that led to the physical altercation with AV. According to the Risk of Harm Letter collected during the APS investigation, W1 was noted as being a high risk for abrupt regression of mental health symptoms related to his/her diagnosis, including hallucinations, manic or depressive episodes, and general destabilization, without proper medication management and monitoring by the facility. The facility’s failure to ensure a safe environment by adequately monitoring and supporting W1’s mental health needs allowed W1 to suffer a sudden behavioral change which led directly to the resident-to-resident altercation between W1 and AV, that caused AV unnecessary and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP26-00468 $375.00 fine assessed