- Date
- 11/28/2025
- Report number
- 00441829-AP-393784
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for their care. AV is a high fall risk with a history of falls and unsteady gait at times, especially at night as AV does not have the ability to use call pendant to call for assistance. AV is care planned for staff to encourage AV to wear proper footwear, and vision aids, to keep path well-lit and clear, keep walker nearby or be helped to sit safely, for staff to retrieve AV’s walker if AV has left it behind and to have motion detection light alarm to use at night to alert care partner or med tech that AV is getting up to use the bathroom. According to an investigation, on or about November 28, 2025, AV was found on the floor in their room. AV was missing a shoe, and facility staff were not using the motion alarm at night. AV was taken to the hospital and diagnosed with a fractured left arm and left leg and required surgery. The facility failed to follow the care plan, which is a violation is neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP26-00585 $2500.00 fine assessed