Violation Details: 00465606-AP-417954

Records Request Print
Date
3/21/2026
Report number
00465606-AP-417954
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide appropriate staffing
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) an (s)
411-054-0028(2)
411-054-0030(1)(e)(A)
411-054-0036(2)(g)
411-054-0070(1)
Findings
On or about March 22, 2026, the Alleged Victim (AV) was found on the floor of his/her room. According to camera footage provided by AV's family, AV fell on March 21, 2026, at approximately 9:00 pm and bruised his/her knee. AV laid on the floor until approximately 8:30 am on March 22, 2026 when he/she was found by staff, causing unreasonable discomfort. AV was not checked on by staff all night. The facility was short staffed and did not have enough staff to cover all residents' needs within the facility. Respondent failed to ensure that enough staff were working in the facility to ensure the needs of all residents were met, causing unreasonable discomfort. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00691 $1500.00 fine assessed