- Date
- 9/1/2025
- Report number
- 00425314-AP-376994
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious 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, and two on August 31, 2025. AV has been seen in the emergency department 8 times in 2025, all visits related to falls. 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 September 1, 2025, AV had an unwitnessed fall in AV's apartment. Facility staff found AV on AV's right side and without AV's walker. AV was sent to the emergency room for increased pain in AV's right leg, and admitted for recurrent falls, diagnosed with fractures of the sacrum and right hip. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect.
- Sanction
- ALFCP26-00098 $500.00 fine assessed