Violation Details: 00425984-AP-377647

Records Request Print
Date
9/11/2025
Report number
00425984-AP-377647
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)(a) and (b)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) lived at Respondent’s facility from June 18, 2025, through September 11, 2025, and relied on facility staff to provide cares and services necessary to ensure the safety of AV. AV's service plan reflected that AV had history of skin breakdown including being at risk for pressure ulcers. The facility staff failed to follow the service plan which led to AV not receiving regular skin checks, hygiene care, and repositioning. On or about September 11, 2025, witness #3 (W3) removed AV's socks after seeing serous fluid saturated on the bed sheet through AV's socks. W3 found open pressure wounds on AV's right heel and left heel. Facility called EMS and AV was transferred to the emergency room department and admitted to the hospital. Respondent failed to provide adequate oversight and supervision of facility staff and Respondent staff failed to follow AV's service plan. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP25-01509 $1125.00 fine assessed