Violation Details: 00442243-AP-394156

Records Request Print
Date
11/21/2025
Report number
00442243-AP-394156
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility for their care. AV is considered high fall risk with a history of falls. AV is care planned for non-slip socks while in bed at night and wearing proper footwear throughout the day. AV is also care planned for alarms to be checked "frequently" to ensure that they are activated/on, including tab alarm for AV's clothing and pressure pad alarms in AV's wheelchair/bed/recliner. According to an investigation, on or about November 21, 2025, experienced a fall, resulting in redness to the right temple. At the time of the fall AV was barefoot and the tab alarms and pressure pad alarms were not activated/on. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP26-00358 $250.00 fine assessed