- Date
- 7/22/2025
- Report number
- 00415426-AP-366756
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for their care. On or about July 22, 2025, an outside care provider watched Witness #4 (W4) wrap a towel around the AV's wrists to restrain his/her arms to keep them from flailing while having his/her hair dried. W4 routinely restrained AV, as staff were advised to check AV after W4 left the facility, to ensure that AV wasn't restrained. On multiple occasions, facility staff found AV restrained with a seatbelt on AV's wheelchair, a safety strap on AV's waist while in bed, or AV's wrists or ankles tied to AV's bed or wheelchair. AV has a history of unintended weight loss, and has lost approximately 20 pounds. AV was care planned to have high calorie pudding, which was often refused by W4. The facility's failure to intervene to ensure the proper care of AV is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01094 $1125.00 fine assessed