Violation Details: 00444688-AP-396679

Records Request Print
Date
12/10/2025
Report number
00444688-AP-396679
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about December 10, 2025, AV had an unwitnessed fall while in the bathroom and was transported to the hospital for evaluation. AV's service planned intervention on November 27, 2025, included AV would be provided a whistle to call for assistance from staff. Prior to the fall on December 10, 2025, AV had not been provided a whistle. The facility failed to provide care planned fall prevention interventions, resulting in pain and compression fractures. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
RCFCP26-00061 $1125.00 fine assessed