Violation Details: 00456792-AP-408994

Records Request Print
Date
2/9/2026
Report number
00456792-AP-408994
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-054-0025
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is a known fall risk, has an unsteady gait and experiences weakness and balance issues. On or about February 9, 2026, AV suffered two falls in his/her room. On fall resulted in hitting AV's head and tailbone. AV's falls are mostly from AV trying to self-transfer. Implemented interventions have not been successful in reducing AV's falls. Respondent failed to ensure interventions were appropriate and successful in reducing AV's risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00538 $375.00 fine assessed