- Date
- 12/10/2025
- Report number
- 00444392-AP-396378
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Witness 1 (W1) is a resident of the facility and relies on staff to provide appropriate supervision to ensure a safe environment. W1 was admitted to the facility on August 14, 2025. Shortly after moving in, W1 demonstrated a progressive pattern of aggressive and violent behaviors that increased in both frequency and severity over time. Based on facility documentation and interviews, on December 10, 2025, at approximately 11:15 a.m., Alleged Victim’s (AV) call light was activated. Facility staff responded to AV's call light and, upon entering AV’s room, found W1 standing over AV holding W1’s wooden cane and AV was bleeding profusely from the face and head. As a result of the incident, AV sustained a facial laceration and skin discoloration to the arms, face, leg, and back. These injuries were directly attributed to W1’s aggressive actions during the incident on December 10, 2025. Prior to the December 10 incident involving W1 and AV, W1 had exhibited a clear pattern of escalating agitation and aggression. Despite W1’s documented history of aggressive behavior, prior physical altercations, and observable behavioral escalation, the facility did not implement adequate precautions, develop appropriate interventions, or provide monitoring consistent with W1’s identified risk level. The facility’s failure to provide sufficient supervision and interventions allowed the December 10, 2025, altercation to occur, resulting in physical harm, pain, and unreasonable discomfort to AV which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP26-00176 $1125.00 fine assessed