Violation Details: 00439855-AP-391700

Records Request Print
Date
11/14/2025
Report number
00439855-AP-391700
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)
411-054-0030(1)(e)(I)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relied on the facility for his/her care. On or about November 14, 2025, the AV had a soiled brief so full of urine that it fell down with AV's pants. AV pants and socks were also soaked with urine. According to an investigation, AV's service plan indicated that AV was incontinent, but staff reported that AV had behaviors and sometimes refused care and assistance with brief changes and/or toileting. When AV refused it often resulted in AV's clothing being soaked with urine. The facility failed to provide services, to include service planning and/or implementing interventions to manage AV's behaviors and care refusals, resulting in a loss of dignity for AV and unreasonable discomfort, which is a violation of resident’s rights, is neglect of care and constitutes abuse as defined by Oregon Administrative Rule 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00569 $375.00 fine assessed