- Date
- 11/1/2025
- Report number
- 00436525-AP-388433
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- On or about November 1, 2025, facility staff observed Witness 1 (W1) seated on a couch with Alleged Victim (AV). W1’s hands were positioned between AV’s legs near the peri area. At the time of the incident, AV was fully clothed and awake. Both W1 and AV were residents under the care and supervision of the facility. Review of facility documentation and staff interviews revealed that W1 had a documented history of inappropriate behaviors, including sexualized actions toward staff and other residents. W1's records indicate these behaviors had been escalating prior to the incident involving AV. Despite evidence of increased risk, the facility did not revise W1’s care plan or implement sufficient interventions to protect AV from W1’s inappropriate conduct. The facility’s failure to act on W1’s known risk behaviors and to implement adequate protective measures resulted in AV experiencing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care, and constitutes abuse.
- Sanction
- RCFCP26-00159 $1125.00 fine assessed