Violation Details: 00427892-AP-379572

Records Request Print
Date
9/21/2025
Report number
00427892-AP-379572
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide service
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
Alleged Victim (AV) relied on the facility for care, required assistance with incontinence care, and has a history of skin breakdown. On or about September 20, 2025, AV did not get their brief changed during day shift, placing AV at risk for skin breakdown. According to an investigation, the Alleged Perpetrator 2 (AP2) was assigned to AV's hallway, but staff reported that AP2 sat in their phone all shift and didn’t help AV. Despite the allegation that AV's briefs were not changed all shift, none of the other on duty staff stepped in to provide AV with care either. The allegation that AP2 failed to provide necessary care was investigated and found to be inconclusive. The facility failed to provide service to the AV, to include ensuring AV's service plan was followed and that AV received incontinence care, placing AV at risk for harm, which is a violation of resident’s rights is neglect of care and constitutes abuse as defined by OAR 411-002-0020(1)(b)(ii).
Sanction
RCFCP26-00639 $375.00 fine assessed