- Date
- 10/29/2025
- Report number
- 00436181-AP-388095
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relied on the facility for care and had a history of falls. On or about October 29, 2025, AV was found on their bathroom floor with a head wound that required approximately 11 staples and one suture. According to an investigation, AV had an outside agency caregiver to be onsite when AV was most active. AV's 1:1 hours were typically 9:00 am to 9:00 pm, but additional hours had just been added to ensure AV had a 1:1 caregiver from 6:00 am - 9:00 am also. Facility staff did not realize that there was no 1:1 caregiver with AV until they found AV on the floor with the head wound. The facility failed to provide services to include, proper service planning and/or implementation of services and ensuring appropriate staffing to ensure AV's safety, which is violation of resident rights, is neglect of care and constitutes abuse as defined by Oregon Administrative Rule 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP26-00634 $1125.00 fine assessed