Date: 11/15/2012
Report Number: CO12128
Allegation: Failed to provide safe environment
Type: Neglect
Level: 3 - Moderate harm or potential for serious harm
Description: The facility failed to evaluate, develop appropriate interventions, monitor and provide an RN assessment and ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing. Resident #2 had wounds that worsened. Resident #3 and #7 lost a severe amount of weight. Resident #8 endangered him/her and other residents due to "helping" by trying to provide care, including toileting, resulting in Resident #1 being injured. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.
Rule(s) Violated: 411-054-0025(4)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(1)(e)
411-054-0040(1) and (2)
411-054-0045(1)(d)(B)
Result: Substantiated
Findings: Civil Penalty due to survey.
Sanction: ALFCP12-063 $1500.00 fine assessed