Violation Details: 00459050-AP-444063

Records Request Print
Date
1/29/2026
Report number
00459050-AP-444063
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate 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) relied on the facility for care and had a history of falls. According to an investigation, there were no fall prevention interventions implemented after AV's falls on February 12, 2026, February 13, 2026, February 17, 2026, February 18, 2026, and February 21, 2026. After a fall on February 17, 2026, the facility recognized AV's need for 1:1 staff but did not implement the intervention, resulting in repeated falls. The facility failed to provide services, to include appropriately care planning and/or that interventions were implemented, placing AV at risk of serious harm, 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)(ii).
Sanction
ALFCP26-00307 $2250.00 fine assessed