Violation Details: 00431423-AP-383218

Records Request Print
Date
10/8/2025
Report number
00431423-AP-383218
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(A) and (G)
411-054-0036(2)(g)
411-054-0070(1)
Findings
The Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff for assistance with hygiene and health-related needs. AV has a documented history of nighttime falls. AV’s service plan includes interventions such as frequent toileting assistance and regular safety checks. On or about October 8, 2025, AV fell while attempting to walk to the bathroom, striking their head and causing redness to the forehead. Required toileting assistance and scheduled safety checks were not completed at the time of the incident due to inadequate staffing. The Respondent failed to follow AV’s service plan and did not provide sufficient staff to meet AV’s assessed needs. This constitutes abuse by neglect as defined in OAR 411-020-0002 (1)(b)(A)(i).
Sanction
ALFCP26-00221 $188.00 fine assessed