Violation Details: 00443552-AP-395518

Records Request Print
Date
12/4/2025
Report number
00443552-AP-395518
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)
Findings
The Alleged Victim (AV) is a known fall risk and has suffered falls at least three times during the month of November. AV's last service plan update was on October 30, 2025. On or about December 4, 2025, AV was found on the floor in his/her room from a fall. AV suffered bleeding to both sides of his/her forehead. AV complained of pain and emergency services were called to assess AV. Respondent failed to ensure proper care planning to reduce the risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00422 $375.00 fine assessed