Violation Details: 00447377-AP-399969

Records Request Print
Date
12/26/2025
Report number
00447377-AP-399969
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
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), 411-054-0040(2)(d)
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 26, 2025, AV was found on the floor and was in pain, resulting in being sent to the hospital for evaluation. AV had at least 5 previous falls between October 8, 2025, and December 26, 2025. AV's service plan had not been updated or changed following each fall. The facility failed to develop fall interventions to address AV’s fall risk, resulting in fall with femur fracture. The facility failed to properly plan care for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
RCFCP26-00431 $1125.00 fine assessed