Violation Details: 00437660-AP-389509

Records Request Print
Date
11/7/2025
Report number
00437660-AP-389509
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)
411-054-0036(2)(g)
Findings
On or about November 7, 2025, the facility failed to respond to the Alleged Victim’s (AV) call light for approximately 1.5 hours. As a result, AV remained in incontinence-soiled clothing, leading to a loss of dignity and unnecessary discomfort. Based on facility documentation and interviews, the facility failed to provide adequate care by not responding to AV’s call light in a timely manner and by not following AV’s care plan, including required scheduled toileting and assistance with unscheduled toileting needs. The facility’s failure to provide necessary care and services resulted in unreasonable discomfort and physical harm to AV which constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00249 $500.00 fine assessed