Violation Details: 00464236-AP-416528

Records Request Print
Date
3/14/2026
Report number
00464236-AP-416528
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) relies on the facility for their care. AV is known to have impaired safety awareness, vision issues, hallucinations and behavior issues. AV is a chronic fall risk with a history of falls, including a previous fall where AV was found in front of their recliner. AV is care planned for assistance with all ambulation/mobility including getting in/out of bed, assistance for transfers and encouraging AV to wear proper footwear. According to an investigation, on or about 03/14/2026, AV was found sitting in front of AV's recliner with h/h wheelchair in front of them and not wearing shoes, posing a risk of harm. The facility failed to provide appropriate services, to include adequate care planning and/or the implementation of effective interventions, which is a violation of resident rights, is neglect of care which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
RCFCP26-00655 $250.00 fine assessed