Violation Details: 00457742-AP-409932

Records Request Print
Date
2/14/2026
Report number
00457742-AP-409932
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide service
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(I)
411-054-0036(2)(g)
411-054-0070(1)
Findings
The Alleged Victim (AV) relied on the facility for care. AV had cognitive decline, an extensive falls history, and was care planned for 1:1 supervision when AV was awake. According to an investigation, on or about February 14, 2026, AV was found on the floor with their left arm pinned between their bed footboard and frame, resulting in a skin tear and bruising. AV did not have a 1:1 with AV when this incident occurred. The facility failed to provide services, including following AV's service plan and ensuring appropriate staffing, which is violation of resident rights, is neglect of care and constitutes abuse as defined by Oregon Administrative Rule 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00567 $375.00 fine assessed