Violation Details: 00474234-AP-426616

Records Request Print Provider Details
Date
5/1/2026
Report number
00474234-AP-426616
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
On or about May 1, 2026, facility staff found the Alleged Victim (AV) on the floor in his/her room. AV is a resident of the Respondent’s facility with a known history of falls. Facility documentation and staff interviews indicate AV was wearing regular socks at the time of the incident, despite a care plan requiring non-slip socks to reduce fall risk. Required fall-prevention interventions were not followed, resulting in AV sustaining physical harm, including a laceration to the eyebrow and an injury to the cheek. The Respondent’s failure to follow AV’s care plan caused unreasonable harm and constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00695 $375.00 fine assessed