- Date
- 6/24/2025
- Report number
- 00409661-AP-360743
- 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) was admitted into a locked memory care facility on or about March 25, 2025, and was dependent on staff (AP1) to meet safety, supervision and AV’s daily care needs. Upon admission, AV’s service plan documented that AV was independent with eating. However, during investigation and interviews staff reported that AV required assistance during meals, indicating a discrepancy between the care plan and AV’s actual needs. AV experienced significant and progressive weight loss. Despite this, there is no documentation that the facility notified AV’s primary care provider (PCP) of the weight loss, nor are there any progress notes indicating that staff monitored the weight loss or implemented interventions to address it. The facility failed to recognize and respond appropriately to AV’s significant weight loss. No individualized or person-centered interventions were documented or implemented, which is a violation of resident’s rights is neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01163 $500.00 fine assessed