Violation Details: 00423266-AP-420446

Records Request Print
Date
8/1/2025
Report number
00423266-AP-420446
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relied on the facility for care and was a known fall risk. According to an investigation, during August 2025, AV experienced approximately eight (8) falls, some resulting in injury to include skin tears, and AV hitting their head requiring a hospital visit. Interventions remained largely reminders and checks, but often lacked defined frequency or consistency. Staff were uncertain regarding how often the checks were actually performed. On or about August 30, 2025, after hearing a loud bang, AV was found on the ground with skin tears to the right hand and left knee. The facility failed to put effective, person-centered interventions in place after repeated falls, which is a violation of resident rights is neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i)(ii).
Sanction
ALFCP26-00219 $1500.00 fine assessed