Violation Details: 00438268-AP-390080

Date
11/7/2025
Report number
00438268-AP-390080
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Findings
On November 7, 2025, Alleged Victim (AV) and Witness 1 (W1) were involved in a resident-to-resident altercation during which W1 struck AV in the face, causing a visible red mark. Facility documentation and staff interviews show that W1 has a history of behavioral incidents and is care-planned to receive appropriate supervision when near other residents. As of October 20, 2025, AV’s care plan required that AV be separated from W1 while in the dining room as an intervention to mitigate known safety risks. At the time of the incident, both AV and W1 were in the dining room without the level of supervision needed to implement these care-plan interventions and protect resident safety. The facility’s failure to provide adequate supervision of W1 and to intervene to prevent the altercation 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
RCFCP26-00228 $375.00 fine assessed