- Date
- 11/28/2025
- Report number
- 00442442-AP-394404
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The investigation determined that the facility failed to implement necessary fall-prevention interventions and did not ensure the Alleged Victim (AV) had an accurate, complete care plan related to AV’s known fall risk. AV is a resident whose care needs are managed by the facility. Although AV experiences some cognitive decline, AV remains alert, oriented, and able to participate in direct care. AV is identified as a fall risk due to a diagnosis affecting memory and cognition. On or about November 28, 2025, AV was found on the floor next to AV’s bed. The investigation established that AV had been moved to a new room at the facility on November 24, 2025. During this move, the bed’s side rails, previously used by AV, were removed and were not reapplied after AV was settled into his/her new room. AV’s care plan did not document the use of any assistive devices, including bed rails, despite their prior use. The facility did not ensure that previously utilized safety measures were reassessed or reinstated following the room change. The facility’s failure to maintain appropriate fall-prevention measures and to update and implement an accurate care plan resulted in AV experiencing an unwitnessed fall and sustaining a serious injury which is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- ALFCP26-00096 $1500.00 fine assessed