- Date
- 1/29/2026
- Report number
- 00459050-AP-411649
- 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 and had a history of falls. On or about February 18, 2026, the Alleged Perpetrator 2 (AP2) went to AV rooms, when AV suddenly stood up and attempted to ambulate and fell, resulting in a head injury. According to an investigation, after a previous fall the facility implemented an intervention to ensure caregivers kept their eyes and hands on AV anytime they were in AV's room. Not all staff were aware there was a new hands-on approach implemented and there was no training on what the new approach looked like until after this fall. The allegation that AP2 failed to follow AV's care plan was investigated and unsubstantiated. The facility failed to provide appropriate services, to include proper care planning and/or the implementation of effective interventions, and ensure staff were fully trained, 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