- Date
- 9/11/2025
- Report number
- 00425984-AP-399252
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- 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, repositioning and placement of cushions. On or about August 5, 2025, AV received a waffle cushion to use while in AV"s recliner. On August 21, 2025, AV had a waffle cushion and gel pad for facility staff to place under AV while AV was sitting in the recliner, however, witness 5 (W5) did not see the waffle cushion under AV. On August 25, 2025, new wounds to AV's left buttock were found, and by September 11, 2025, when AV was transferred to the hospital the wounds to AV's buttock developed into a pressure ulcer. 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