Violation Details: 00477957-AP-430429

Records Request Print
Date
5/20/2026
Report number
00477957-AP-430429
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide safe environment
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)
411-054-0060(2) and (4)
Findings
On or about May 20, 2026, the Alleged Victim (AV) was found on the floor of his/her room, wedged between his/her transfer pole and bed. AV's skin was a blue/ purple color and AV was gasping for air. AV was transferred to the hospital and admitted after his/her emergency room visit. The transfer pole in AV's room was not care planned, nor was it assessed or the resident informed of the risks and benefits of the device. At the time of this incident, AV was no longer able to use the transfer pole, and it should have been removed from the room. Respondent failed to ensure a safe environment for AV, by allowing the transfer pole to remain in place without properly assessing the device at any time, training staff, or documenting the use of the transfer pole. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00299 $375.00 fine assessed