Violation Details: 00446847-AP-398898

Records Request Print
Date
12/23/2025
Report number
00446847-AP-398898
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)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility for their care. AV has a history of falls; AV is known for not always using the call pendant to call for assistance and self-ambulates in AV's apartment regularly. AV is care planned for staff assistance to transfer safely and has a bed alarm. According to an investigation, on or about December 23, 2025, AV suffered an unwitnessed fall in AV’s room, resulting in an upper left eye lid injury. According to AV, AV had fallen while walking to the bathroom due to a loss of balance. AV’s bed alarm was not functioning at the time of the fall. The facility failed to follow the care plan, which is a violation is neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00602 $375.00 fine assessed