Violation Details: 00444851-AP-396867

Records Request Print
Date
12/10/2025
Report number
00444851-AP-396867
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide inservice
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)(b)
Findings
The Alleged Victim (AV) was independent in all care needs prior to November 2025 when he/she was hospitalized due to a fall. AV returned from the hospital on hospice services and his/her care was changed to a two person transfer for assistance and toileting. On or about December 10, 2025, Alleged Perpetrator #2 (AP2) was assisting AV with toileting and left AV alone, assuming that AV's spouse was watching AV. AV fell and hit his/her face, causing swelling and bruising. AV's service plan did not indicate that staff could not leave AV alone. Respondent failed to ensure staff followed the service plan and ensure that staff were properly trained prior to providing care to residents. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
ALFCP26-00059 $250.00 fine assessed