Violation Details: 00445970-AP-398014

Records Request Print
Date
12/14/2025
Report number
00445970-AP-398014
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-05-0027(1)(g) and (s)
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) suffered 8 falls within 30 days, suffering bruises, skin tears, hitting his/her head and unreasonable discomfort. AV was not care planned as a fall risk. AV was prescribed a wheelchair by his/her physician, however, it doesn't appear, according to documentation, that it was being utilized. The facility had not implemented meaningful interventions to reduce AV's risk for falls. Respondent failed to ensure staff implemented interventions to reduce AV's risk of falling. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00300 $500.00 fine assessed