Violation Details: 00457336-AP-409553

Records Request Print
Date
2/11/2026
Report number
00457336-AP-409553
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility for their care. AV has a history of falls and is care planned for stand-by assistance for transfers & ambulation. According to an investigation, on or about February 11, 2026, AV was standing in the middle of the TV room without assistance. AV turned around and tripped over their right foot, causing AV to fall. AV experienced knee pain and a skin tear and was sent to the hospital where they were diagnosed with a fracture to their right femur. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP26-00485 $1125.00 fine assessed