- Date
- 9/12/2025
- Report number
- 00429155-AP-380888
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- The facility failed to provide necessary care and services as required by the Alleged Victim’s (AV) care plan and assessed needs. Based on facility documentation and interviews, AV had an active wound on the right foot under his/her big toe and was receiving home health services until discharge on 9/8/25, at which time the wound was nearly healed. On 9/10/25, 9/13/25, and 9/17/25, facility staff did not assess or observe AV’s wound, despite AV’s care needs and the requirement to provide ongoing wound monitoring. Staff relied solely on the presence of clean, dry, intact bandages applied by AV’s medical provider on 9/12/25 and failed to assess the underlying wound. Failure to provide required monitoring and nursing oversight resulted in deterioration of AV’s wound, causing unreasonable discomfort, pain, and physical harm, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- ALFCP26-00126 $500.00 fine assessed