- Date
- 8/22/2025
- Report number
- 00425314-AP-376991
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) lives at Respondent’s facility and relies on facility staff for AV's care and safety needs. AV has a fall history, including an incident that occurred on June 11, 2025. AV's service plan, reflects that AV has a fall history and needs observation, has ability to self-transfer and ambulate with and without AV's walker, AV has no observable safety awareness deficits, has some short-term memory loss/confusion and forgetfulness- reorient as needed, and states AV has not had any falls since November 2024. However, the facility failed to develop sufficient person-centered interventions to mitigate risk to AV. On or about August 22, 2025, AV had an unwitnessed fall and was found on the floor in AV's apartment, next to AV's recliner. AV had a small, raised bump with bruising on the back of AV's head and a small bruise on AV's finger. AV was sent to the emergency room for evaluation. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect.
- Sanction
- ALFCP26-00098 $500.00 fine assessed