- Date
- 6/12/2025
- Report number
- 00407790-AP-358823
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a therapeutic diet
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility to manage their physician ordered specialized therapeutic diet. The AV had care plan interventions for meals, including but not limited to, monitoring, cueing, reminders to chew thoroughly, and encourage water if appears to be struggling to chew or swallow. According to an investigation, on or about June 12, 2025, the AV was served a dry Philly Melt sandwich for the evening meal. The AV was not monitored while eating. The AV choked on the sandwich, became unresponsive, and was taken to the hospital by EMS. The facility failed to follow the AV’s therapeutic diet order and failed to follow the AV's care plan, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.
- Sanction
- ALFCP25-00401 $1500.00 fine assessed