Violation Details: 00457849-AP-410615

Records Request Print
Date
2/14/2026
Report number
00457849-AP-410615
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(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) is a known fall risk and has had falls at a previous facility. AV takes pain medication that may make him/her have dizziness, leading to falls. On or about February 14, 2026, AV suffered a fall in his/her room when he/she slid from his/her bed and hit his/her right side and had right temporal pain. Emergency services were called to assess AV after the fall. Respondent failed to ensure proper care planning to prevent falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00286 $250.00 fine assessed