- Date
- 4/8/2025
- Report number
- 00397381-AP-348051
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The facility failed to provide services in accordance with the Alleged Victim’s (AV) assessed toileting needs and established care plan. AV is a resident of the facility and is care-planned to receive toileting assistance two to three times per shift. Based on a review of facility documentation and staff interviews, during the week of April 8, 2025, Witness 1 (W1) consistently found AV saturated in urine during day shift. These observations demonstrate that staff did not follow the care plan as written. W1 reported the concerns to supervisory staff; however, supervisory staff failed to respond appropriately to the reported concerns, resulting in inadequate toileting assistance, poor hygiene, and insufficient monitoring. AV did not have documented incontinence-related complications, indicating the condition was preventable with appropriate care. The facility’s failure to follow AV’s care plan caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care, which constitutes abuse.
As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.