- Date
- 3/7/2026
- Report number
- 00462513-AP-414849
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- 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 March 7, 2026, AV was found on the floor in their room with a gash to their head during a safety check. AV's service planned interventions were for staff to provide safety checks every two hours and at the start and end of each shift, offer assistance with toileting needs and make sure items were within reach. AV experienced at least 8 falls in the previous 3 months and fall interventions remained unchanged until after the fall on March 7, 2026. In addition, AV's progress notes documented AV was having increasing need for assistance with mobility and care. The facility did not develop or implement any known changes to AV's care plan following the falls. The facility failed to develop fall interventions to address AV’s fall risk, resulting in injury. 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
- RCFCP26-00338 $500.00 fine assessed