Violation Details: 00465817-AP-418186

Records Request Print
Date
3/23/2026
Report number
00465817-AP-418186
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-054-0025(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 care. On or about March 23, 2026, AV fell two times on the same day. According to an investigation, the facility did not put interventions in place after the first fall to mitigate AV's fall risk, resulting in AV having another fall requiring a hospital visit. The facility failed to put effective, person-centered interventions in place after a fall, which is a violation of resident rights is neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00276 $500.00 fine assessed