Violation Details: 00463445-AP-415775

Records Request Print
Date
3/12/2026
Report number
00463445-AP-415775
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
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)
Findings
On or about March 13, 2026, the Alleged Victim (AV) sustained a fractured nose, lacerations, and bruising following an unwitnessed fall at the Respondent’s facility, where the AV resided at the time of the incident. Facility documentation and interviews indicate that the AV has a history of frequent falls and is identified as a fall risk. Despite the AV’s known history of frequent falls and identified fall risk, the facility failed to develop or implement adequate interventions to mitigate that risk. The Respondent’s failure to properly care plan for the AV’s fall risk resulted in unreasonable harm to the AV which constitutes abuse by neglect, as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00678 $338.00 fine assessed