Violation Details: 00442815-AP-394838

Records Request Print
Date
11/13/2025
Report number
00442815-AP-394838
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0070(1)
Findings
The Alleged Victim (AV) is a known fall risk and has suffered multiple falls with and without injury between October 25, 2025, and November 13, 2025. AV's service plan was not updated to reflect AV's pattern of falls. Interventions were created after October 7, 2025, to include cuing, reminding the resident to call for assistance, however, upon investigation, no call light or pendant was seen near AV to be able to call for assistance from staff. Respondent failed to ensure proper care planning and meaningful interventions what would reduce AV's risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00385 $500.00 fine assessed