Violation Details: 00458840-AP-411089

Records Request Print
Date
2/18/2026
Report number
00458840-AP-411089
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
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)
Findings
The Alleged Victim (AV) is a known fall risk and has suffered four falls recently. AV is care planned for frequent checks 4 times per shift and staff are to keep eyes on AV while in the common area to reduce the risk of falls. On or about February 18, 2026, AV was anxious and restless and wanted to move a recliner and lost his/her balance and fell. No staff were in the common area to assist AV, and AV was agitated to the extent of needing medication for AV to settle down. Respondent failed to ensure AV's safety from falls and ensure staff were available for the safety of residents. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00483 $375.00 fine assessed