Violation Details: 00460447-AP-412723

Records Request Print
Date
2/26/2026
Report number
00460447-AP-412723
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation
Failed to properly plan care
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)
411-054-0040(1)(a) and (d)
Findings
On or about February 26, 2026, Alleged Victim (AV), a newly admitted resident with a known history of falls, was found on the floor of his/her room. Based on facility documentation and interviews AV’s admission to the facility had been delayed because AV experienced a fall prior to admission and required a rehabilitation stay. After rehabilitation, AV’s care needs had increased significantly compared to the facility’s initial pre-admission assessment. The facility failed to reassess AV’s care needs following AV's rehabilitation stay and did not complete the required fall-risk evaluation. Despite clear indicators that AV was at high risk for falling, the only intervention implemented was checking on AV twice per shift. Due to this inadequate assessment and failure to provide necessary fall-prevention supports to mitigate AV's fall risk, AV fell and sustained severe injuries, including swelling, a brain bleed, and the need for intubation. The facility’s failure to evaluate and meet AV’s care needs caused AV unreasonable discomfort and hospitalization which is defined as abuse as indicated in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00296 $1500.00 fine assessed