Violation Details: 00462073-AP-414385

Records Request Print
Date
3/7/2026
Report number
00462073-AP-414385
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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
The Alleged Victim (AV) relies on the facility for their care. AV is care planned for physical assistance with showers. AV is known not to use the call pendant, and staff are to provide routine checks on AV to ensure AV’s needs are met. Before meals staff are to help AV get dressed and escort AV down to breakfast, this would happen around 7:30 AM because breakfast is at 8:00 AM. According to an investigation, AV fell around 8:00 -8:15 AM on or about March 7, 2026, resulting in a fractured sacrum and a contusion on AV's right hand. AV was still in their robe at the time of the fall. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00267 $375.00 fine assessed