Violation Details: 00457834-AP-410050

Records Request Print
Date
2/15/2026
Report number
00457834-AP-410050
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility for their care. AV is care planned for assistance when ambulating in a wheelchair and for toileting, showering and transfers. AV has a history a history, including when needing to use the restroom. According to an investigation, on or about, February 15, 2026, AV fell while attempting to get out of bed to use the restroom, resulting in a fractured ankle. AV pressed their call light after the fall and according to the alert system, AV's call light went off for over 30 minutes. The facility failed to provide appropriate services, to include adequate care planning and/or the implementation of effective interventions and not answering the call light timely, which is a violation of resident rights, is neglect of care which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00295 $1125.00 fine assessed