Violation Details: 00433428-AP-385446

Records Request Print
Date
10/19/2025
Report number
00433428-AP-385446
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
External site: 411-054-0036(2)(g), 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility for his/her care and to administer his/her medications. AV had a history of falls and had not been using a call pendant for some time. According to an investigation, on or about October 19, 2025, AV was found on the floor in their room by a visitor at around 11:00 am. AV did not receive their 8:00 am medication as ordered and had not been checked on by staff, resulting in AV experiencing a fall with injury to the knee. AVs care planned fall interventions had not been updated to address reduced ability to use a call pendant to call for assistance. The facility failed to properly plan care and failed to administer medication as ordered, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP26-00051 $188.00 fine assessed