Violation Details: 00436469-AP-388326

Records Request Print
Date
10/31/2025
Report number
00436469-AP-388326
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(H) and (I)
Findings
Alleged Victim (AV) and Witness 1 (W1) reside in the Respondent’s facility and depend on facility staff for their daily needs and for maintaining a safe environment. W1 has a documented history of behavioral issues involving other residents, including resident-to-resident altercations. These behaviors have resulted in multiple prior incidents in the dining room, including one in April 2025 and three in July 2025. On or about October 31, 2025, facility staff discovered the aftermath of resident-to-resident altercation involving AV and W1. W1 was found lying on the floor next to a dining room chair with a skin tear on the right forearm and the left jaw/cheek. W1 also reported head pain consistent with hitting their head. AV sustained a skin tear on the left hand. The Respondent failed to provide adequate oversight and to ensure a safe environment for residents. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00586 $375.00 fine assessed