- Date
- 11/1/2025
- Report number
- 00437320-AP-389357
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- On or about November 1, 2025, the Alleged Victim (AV) fell forward while leaning in AV’s wheelchair, resulting in a bump to the center of AV’s forehead with visible skin discoloration. Based on facility documentation and staff interviews, the facility did not follow the interventions that had been implemented to prevent falls. This failure contributed to the fall on 11/01/2025 and the resulting injury. The facility’s failure to provide necessary care and services to mitigate AV's fall risk, resulted in unreasonable discomfort and physical harm to AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- RCFCP26-00198 $250.00 fine assessed