Violation Details: 00459050-AP-444066

Records Request Print
Date
1/29/2026
Report number
00459050-AP-444066
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, had a history of falls, and used a fall alarm to alert staff of AV getting up. Between February 6, 2026, and February 16, 2026, the facility documented five (5) falls that AV's fall alarm did not sound prior to staff finding AV on the floor. According to an investigation, the facility indicated the alarms are "finicky" and expensive, and the facility attempted to have staff "pair" AV's fall alarm prior to purchasing a new, functional unit. The facility failed to provide services, to include ensuring proper care planning and/or interventions were implemented and that equipment was in good working order, 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