Violation Details: 00463612-AP-415923

Records Request Print Provider Details
Date
2/2/2026
Report number
00463612-AP-415923
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings
Alleged Victim (AV) relies on the facility for his/her care. AV had four (4) falls in February 2026, one (1) resulting in injuries to AV. AV reported not being able to ambulate on his/her own. Although it was note charted that on or about February 3, 2026, AV was placed on hourly checks as well as given a urinal hat that AV could use from h/h bed, the information was not added to AV's service plan or temporary service plans. The service plans dated February 2, 2026, February 4, 2026, and February 19, 2026, only mention facility staff to report delayed injuries. On or about February 22, 2026, AV had a significant change of condition regarding his/her frequent falls, but no new interventions were added. Respondent failed to develop and implement suitable interventions for falls. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(A)(ii) and violates the following OARs:
Sanction
RCFCP26-00565 $500.00 fine assessed