Violation Details: 00441618-AP-393596

Date
11/25/2025
Report number
00441618-AP-393596
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
The facility failed to implement appropriate interventions and update the care plan related to the Alleged Victim’s (AV) known behavioral history and recent increase in altercations. The facility’s failure to recognize, assess, and address AV’s escalating behaviors resulted in an altercation between AV and Witness 1 (W1) in the hallway, during which both individuals struck one another with open hands. As a result of the incident, AV was observed with blood from a laceration on the right temple, discoloration to the right hand, and was later found to have a fracture of the right pinky finger. AV has a documented history of multiple altercations with other residents. The facility failure to develop and implement suitable interventions caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP26-00230 $1125.00 fine assessed