- Date
- 9/5/2025
- Report number
- 00425215-AP-376769
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) returned to the facility on September 3, 2025, after a hospital stay with a diagnosis of “failure to thrive.” Due to AV’s change in condition, staff were required to deliver meals to AV’s apartment, place them within AV’s reach, and provide cuing to eat. On the afternoon of September 5, 2025, AV’s breakfast and lunch trays were found in AV’s room untouched, still covered, and positioned out of AV’s reach. Based on facility documentation and interviews, staff working with AV at time of incident were not aware of AV’s need for meal setup and cuing. When staff made AV’s food accessible and provided cuing, AV began eating. The facility's failure to provide adequate oversight and training of staff to ensure AV was receiving necessary meal support, resulted in unreasonable discomfort when AV was not able to eat meals which were left in AV's room. The facility failed to properly care plan for AV's care needs which resulted in unreasonable discomfort and physical harm to AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- ALFCP26-00210 $250.00 fine assessed