Violation Details: 00454148-AP-406235

Records Request Print
Date
1/27/2026
Report number
00454148-AP-406235
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is care planned as independent with mobility, however, requires a one-person standby assist for transfers. AV has a history of inconsistent walker use, which has been identified as a contributing factor in prior falls. On or about January 27, 2026, AV was found on the floor by care staff. AV suffered an abrasion and bruising to his/her right shoulder and expressed pain. At the time of this incident, AV had been identified as a low fall risk and therefore did not have fall preventions in place. Respondent failed to ensure proper care planning to reduce the risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00495 $500.00 fine assessed