- Date
- 12/3/2025
- Report number
- 00459147-AP-411395
- 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 for assistance with repositioning and transfers. Home Health wound care services were in place and directed use of a 'slippery sheet" with handles for use when repositioning the AV to prevent shearing injuries. According to an investigation, the "slippery sheet" was not used, and the AV was identified with an open wound to the left buttock on or about December 3, 2025. The wound worsened and Home Health was contacted for treatment. On or about February 20, 2026, Home Health observed a Stage 2 shearing wound to the AV's left sacral area. The facility failed to follow the care plan, which is a violation of residents' rights, is neglect of care, and constitutes abuse.
- Sanction
- RCFCP26-00335 $500.00 fine assessed