- Date
- 1/29/2026
- Report number
- 00459050-AP-411647
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relied on the facility for care. According to an investigation, on or about January 29, 2026, AV had an unwitnessed fall around 3:09 pm and declined staff assistance to get up from the floor. There was no Temporary Service Plan or new interventions added to AV's Service Plan to ensure AV's safety and prevent future falling. Then later the same day, at approximately 7:39 pm, AV fell again breaking their ribs. The facility failed to provide appropriate services, to include proper care planning and/or the implementation of effective interventions and resident monitoring, resulting in repeated falls, broken ribs, and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- ALFCP26-00307 $2250.00 fine assessed