Violation Details: 00438708-AP-390520

Records Request Print
Date
11/12/2025
Report number
00438708-AP-390520
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings
The Alleged Victim (AV) is a known fall risk and is to have a bed alarm turned on during night shift to alert staff if AV is getting up. On or about November 12, 2025, AV was found on the floor in his/her room after he/she fell after getting out of bed. AV's bed alarm either wasn't turned on or wasn't working, placing AV at risk for harm. Respondent failed to provide a safe environment by not ensuring AV's bed alarm was on or working properly. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
RCFCP26-00539 $375.00 fine assessed