- Date
- 12/30/2025
- Report number
- 00448254-AP-400265
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for care, is a fall risk, and is care planned for a fall mat to be in place when AV is in bed. On or about December 30, 2025, AV fell out of bed resulting in a head wound. According to an investigation, AV's fall mat was not in place at the time of the fall. Steri-strips were put in place to close the wound, but AV was ultimately sent to the emergency room. The facility failed to follow AV's care plan to ensure a fall mat was in place, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP26-00207 $1125.00 fine assessed