Violation Details: 00460306-AP-412587

Records Request Print
Date
2/26/2026
Report number
00460306-AP-412587
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
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
On or about February 26, 2026, the Alleged Victim (AV) was found on the floor of his/her room. It is unknown how long AV was on the floor at the time of being found. AV was a known fall risk and was to have safety checks four times per shift, however, the facility was short staffed, and AV did not get checked on as care planned. AV suffered an abrasion and pain to his/her forehead. Respondent failed to ensure staff followed the care plan, ensuring AV's safety from falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00563 $375.00 fine assessed