Violation Details: 00446264-AP-398593

Records Request Print
Date
12/18/2025
Report number
00446264-AP-398593
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(F)
411-054-0036(2)(g)
411-054-0070(1)
Findings
The Alleged Victim (AV) is care planned to have meal attendance where staff are to monitor for refusal of dining room meals and behaviors related to meals. Staff are to encourage AV to the dining room and if AV refuses, staff are to monitor AV in his/her room during the meal and recover all dishes when AV completes the meal. On or about December 18, 2025, at approximately 2:30 pm, AV was walking in his/her room without his/her walker, carrying dishes across the room to AV's bathroom when AV lost his/her balance and fell to the floor hitting his/her head. AV was sent out to the hospital for evaluation. Respondent failed to ensure staff read and followed the service plan and ensure there were enough staff present to ensure all residents needs were met. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00658 $188.00 fine assessed