- Date
- 8/3/2025
- Report number
- 00418045-AP-369377
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is a known fall risk and is care planned for one to one care on all shifts. There is some confusion about AV's one to one care, as some staff mention one to one care is only from 2:00 PM to 10:00 PM, however TSP's claim AV is to be on one to one care all shifts. AV's care plan also indicates AV is to have 3-5 checks per shift and have checks 8 times per shift. On or about August 3, 2025, AV was found on the floor in his/her room, and AV's brief and bed were soaked with urine. The facility failed to follow AV's care plan, resulting in AV being found on the floor and being soaked in urine, placing AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01173 $375.00 fine assessed