Violation Details: 00473008-AP-425332

Records Request Print
Date
4/28/2026
Report number
00473008-AP-425332
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
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) relied on the facility for his/her care and was care planned for a nonslip pad to be under them while seated. On or about April 28, 2026, AV was found on the floor after falling out of the recliner resulting in a hematoma. According to an investigation, AV had been sitting in a recliner in their room all night, and despite multiple staff interacting with AV, no one moved AV's nonslip pad from their wheelchair to the recliner they were sitting in, contributing to the fall. The facility failed to follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00687 $500.00 fine assessed