- Date
- 8/31/2025
- Report number
- 00425314-AP-376993
- 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 August 22, 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 31, 2025, AV had an unwitnessed fall at approximately 5:30pm, facility staff found AV on the floor in AV's apartment on h/h back. At approximately 6:50pm AV fell again unwitnessed, in AV's bathroom. AV was found by facility staff on the floor and without AV's walker. AV was unable to bear weight and sent to the emergency room for severe pain in AV's backside. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect.
- Sanction
- ALFCP26-00098 $500.00 fine assessed