- Date
- 1/25/2026
- Report number
- 00453020-AP-405095
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- On or about January 25, 2026, at approximately 3:37 AM, the Alleged Victim (AV) was found on the floor in his/her room after tripping and falling. AV complained of shoulder pain and was transported to the hospital, where AV was diagnosed and treated for a right-humerus fracture. Based on facility documentation and staff interviews, the facility failed to reassess and implement effective fall-prevention interventions for AV following each fall prior to incident. The facility’s failure to reevaluate AV’s fall risk and implement appropriate fall-prevention measures resulted in continued unreasonable discomfort and increased risk of harm, culminating in AV sustaining a fractured right humerus, which is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP26-00598 $1125.00 fine assessed