- Date
- 4/30/2025
- Report number
- 00400323-AP-351144
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care needs. AV had shared with multiple people that Alleged Perpetrator 2 (AP2) would take AV to AV’s room, close the door, and force medications into AV’s mouth by forcibly restricting AV’s movement of the face or neck. Alleged Perpetrator 3 (AP3) made the determination to chart AV as having a history of false allegations per a statement made by AV’s family member that AV had made allegations against staff at a previous facility. AP3 also stated that weeks prior to the start of the investigation, AP3 had received direct information about a staff member holding AV down and forcing AV to take medication, but AP3 had ruled out the concern simply because no staff of the reported gender had been working the day it was reported. AP2 failed to protect AV from wrongful restraint, which is neglect of care and constitutes abuse, AP3 failed to provide a safe environment for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe environment for AV, which is a violation of Oregon Administrative Rules.