- Date
- 5/25/2025
- Report number
- 00415491-AP-366897
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) lives at Respondent’s facility and relies on facility staff to provide care and services necessary to ensure the safety of AV. AV has a history of falls, including a fall on April 29, 2025, while getting out of the shower which resulted in an abrasion to AV's right elbow. In additional AV fell in Witness #1 (W1) bathroom on May 21, 2025, AV was not conscious when found and seen at the Emergency Room. AV's progress notes reflect AV is unsteady while standing and needing stand by assistance with toileting. However, the facility failed to develop sufficient interventions to mitigate risk to AV. On or about May 25, 2025, AV and W1 were found by facility staff after AV and W1 had finished showering together. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(ii).
- Sanction
- RCFCP25-01483 $500.00 fine assessed