- Date
- 8/21/2025
- Report number
- 00421883-AP-373344
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- In August 2025, a significant failure in care occurred involving an Alleged Victim (AV) who was under the facility's care at time of incident. On August 11, 2025, AV reported a pressure sore on his/her coccyx area and described experiencing sharp pain at the site. Facility documentation and staff interviews confirmed the presence of a wound measuring approximately 1.5 cm by 0.4 cm, with no visible drainage. Despite this discovery, the facility did not initiate wound care or document AV’s change in condition. AV was seen by his/her physician on or about August 21, 2025, who confirmed the wound on AV coccyx area. By then, the condition had worsened, resulting in unnecessary discomfort and physical harm to AV. The facility’s failure to provide timely and appropriate care is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- RCFCP25-01136 $500.00 fine assessed