Violation Details: 00431152-AP-382981

Records Request Print
Date
10/7/2025
Report number
00431152-AP-382981
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
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)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) moved into the facility on or about October 1, 2025. AV was listed as independent with ambulation and transfers. AV suffered three falls within the first week of being at the facility, two of the falls resulted in injuries to AV's head. On or about October 7, 2025, AV was sitting in the dining room and stood up from the table and fell backwards, hitting his/her head. AV went on to have another fall on October 24, 2025, resulting in another head injury. The facility's failure to ensure person centered interventions and supervision lead to AV having multiple falls, which constitutes neglect by abuse, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00003 $375.00 fine assessed