Violation Details: 00470013-AP-422324

Records Request Print
Date
4/8/2026
Report number
00470013-AP-422324
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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)
411-054-0040(1) and (2)
Findings
The Alleged Victim (AV) relies on the facility for care, has a history of skin breakdown, and is care planned for assistance with incontinence care, medications, and repositioning. On or about April 8, 2026, it was brought to the attention of the facility that AV had a skin issue consisting of redness on their buttock. There was no additional monitoring or documentation for the next five (5) days until AV's skin opened and caused AV pain. According to an investigation, facility staff were unclear on how often AV was repositioned and some staff said they used barrier cream for skin issues, while others thought powder was used. The facility failed to provide appropriate services, to include proper care planning and/or the implementation of effective interventions, to assess AV for change of condition, and resident monitoring, resulting in AV's skin breakdown and pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00279 $1500.00 fine assessed