Violation Details: 00485057-AP-437675

Records Request Print
Date
6/21/2026
Report number
00485057-AP-437675
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
On or about June 21, 2026, Alleged Victim (AV), a resident of the Respondent’s facility, fell while attempting an independent transfer from his/her recliner chair to his/her electric scooter. Facility documentation and staff interviews confirm that AV previously fell on October 21, 2025, February 9, 2026, March 25, 2026, and June 5, 2026. Despite this documented fall history, AV’s service plan dated May 14, 2026, failed to contain appropriate fall-prevention interventions to mitigate AV's fall risk. The facility also failed to complete or update an Individual Service Plan (ISP) with fall-prevention measures following AV’s June 5, 2026, fall. The facility’s failure to identify, assess, and implement appropriate care-planning for AV’s ongoing fall risk resulted in AV sustaining a serious fall on June 21, 2026, causing a fractured vertebra and facial injuries. This failure to provide adequate care and supervision caused AV unreasonable harm which constitutes abuse by neglect, as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00679 $375.00 fine assessed