Violation Details: 00435290-AP-387361

Records Request Print
Date
10/24/2025
Report number
00435290-AP-387361
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)(a) and (b)
411-054-0036(2)(g)
Findings
Alleged Victim (AV) and Witness 1 (W1) reside in the Respondent’s facility and depend on facility staff for their daily needs and safety. W1 has a documented mental health diagnosis and a history of verbally aggressive and assaultive behaviors, including hitting, with a prior incident occurring on October 17, 2025. On or about October 24, 2025, facility staff failed to follow W1’s service plan. W1 was left unsupervised while agitated and attempting to enter other residents’ rooms. Staff subsequently heard screaming from AV’s room. Upon entering, staff observed AV sitting on the bed holding their eye. AV reported that W1 had slapped them in the face. The Respondent’s failure to follow the service plan constitutes abuse by neglect, as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00574 $500.00 fine assessed