Violation Details: 00447949-AP-400003

Records Request Print
Date
12/30/2025
Report number
00447949-AP-400003
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
411-054-0036(2)(g)
411-054-0040(1)(d)(A)(B)
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 30, 2025, AV experienced a fall out of a recliner while seated in the common area. AV had several previous falls from November 6, 2025 through December 26, 2025. The service planned interventions were for staff to provide verbal cuing as needed and increase observation. The facility did not consistently develop or implement any known changes to AV's care plan following the falls or evaluate the effectiveness of interventions. The facility failed to develop fall interventions to address AV’s fall risk, resulting in injury and requiring hospitalization for evaluation and treatment, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
RCFCP26-00664 $375.00 fine assessed