Violation Details: 00469181-AP-421519

Records Request Print
Date
2/27/2026
Report number
00469181-AP-421519
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
The Alleged Victim (AV) relies on the facility for his/her care and has a history of falls. According to an investigation, on or about February 27, 2026, AV experienced a fall, resulting in a fracture to their right cheekbone. AV experienced another fall on or about March 2, 2026, resulting in a head injury. The facility failed to appropriately plan care and/or implement interventions to mitigate the risk of injury, which is a violation of resident rights, is neglect of care which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00718 $500.00 fine assessed