- Date
- 9/15/2023
- Report number
- 00283350-AP-404456
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for care and supervision. According to an investigation, the Alleged Perpetrator 3 (AP3) was completing an internal investigation to rule out an allegation of abuse of residents by the Alleged Perpetrator 2 (AP2). AP3 indicated that their internal investigation was complete and there was no evidence of the abuse. AP3 reinstated AP2 and bought them back to work. AP3 did not complete a thorough investigation and during interviews with staff members that worked with AP2, approximately four (4) staff members indicated they had previously observed AP2 physically restrain and engage in aggressive and forceful behavior with residents. AP3 brought AP2 back to work and on or about September 15, 2023, AP2 placed AV in a "Full Nelson" hold, picked AV up, and forcefully moved AV into a dining room chair. AV yelled, "No," and "Stop," when this occurred. AP3 's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe environment, and ensure AV was free from abuse, which is a violation of Oregon Administrative Rules.