Violation Details: 00449925-AP-401870

Records Request Print
Date
1/9/2026
Report number
00449925-AP-401870
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
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) relied on the facility for care and had a history of a recent fall. On or about January 9, 2026, AV had an unwitnessed fall in their room, resulting in at hip fracture. According to an investigation, AV had recently been ill and had a fall approximately 4 days earlier due to weakness. The failed to properly care plan and/or implement interventions after AV's recent fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00666 $375.00 fine assessed