Violation Details: 00451961-AP-403979

Date
1/19/2026
Report number
00451961-AP-403979
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
The Alleged Victim (AV) was a known fall risk and had suffered falls recently. On or about January 19, 2026, AV suffered a fall from his/her wheelchair and suffered a skin tear to his/her arm. AV is known to transfer without asking for assistance, although interventions in place are to remind AV to request assistance. Interventions in place were repetitive with no new interventions created, placing AV at risk for harm. Respondent failed to ensure new interventions were created to ensure AV's safety from falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00514 $375.00 fine assessed