Violation Details: 00462249-AP-414563

Records Request Print
Date
3/7/2026
Report number
00462249-AP-414563
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 was a known fall risk. According to an investigation, on or about March 7, 2026, AV was observed attempting to stand up and hit another resident, resulting in a fall in which AV hit their head. AV was taken to the hospital where they were diagnosed with a concussion. The facility failed to provide appropriate services, to include proper care planning and/or the implementation of effective interventions and resident monitoring, resulting in unreasonable discomfort, 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)(i).
Sanction
RCFCP26-00667 $500.00 fine assessed