- Date
- 9/16/2025
- Report number
- 00427149-AP-378800
- 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) relies on the facility to follow physician's orders and provide meals. The AV has a physician's order for pureed foods and was care planned to receive the altered diet. According to an investigation, on or about September 16, 2025, the AV was given solid foods by Alleged Perpetrator 2 (AP2), placing the AV at risk for choking. AP2’s actions are a violation of resident rights, considered neglect, and constitute abuse. The facility failed to follow the AV’s diet orders and care plan, which is a violation of resident’s rights, is neglect of care, and constitutes abuse. The allegation that Alleged Perpetrator 3 (AP3) , Alleged Perpetrator 4 (AP4), and Alleged Perpetrator 5 (AP5) failed to follow the AVs care plan and physician's orders was investigated and determined to be inconclusive.
- Sanction
- RCFCP25-01370 $188.00 fine assessed