Violation Details: 00456379-AP-408534

Records Request Print
Date
2/6/2026
Report number
00456379-AP-408534
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide appropriate staffing
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: 411-054-0030(1)(e)(A)
External site: 411-054-0037(5) and (6)
External site: 411-054-0070(1)
Findings
The Alleged Victim (AV) has a history of falls and has been in physical therapy. On or about February 6, 2026, AV fell in his/her room and had crawled out into the hallway to find staff for assistance. AV did not find anyone to assist him/her, as there were not staff available near AV's room due to short staffing at the facility. AV suffered a goose egg to his/her head and was sent to the hospital for evaluation. Respondent failed to ensure the proper number of staff were working to meet the scheduled and unscheduled needs of the residents were met, causing unreasonable discomfort to AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00522 $250.00 fine assessed