Violation Details: 00408230-AP-359283

Records Request Print Provider Details
Date
6/15/2025
Report number
00408230-AP-359283
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(H)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is cognitively impaired and requires staff monitoring in common areas and outside. On or about June 15, 2025, AV suffered an unwitnessed fall outside that resulted in AV suffering a fractured clavicle, which caused pain and unreasonable discomfort. Staff were unaware that AV was outside alone for approximately 20 minutes. Respondent failed to ensure staff followed the service plan to ensure AV's safety. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00173 $1125.00 fine assessed