- Date
- 11/25/2025
- Report number
- 00442006-AP-438388
- 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 safety. On or about November 25, 2025, at approximately 12:30 am, AV was found standing in the facility hallway complaining of pain to AV's head and right wrist. AV was observed by staff to have a swollen wrist and a bump on their forehead. Staff assisted AV to bed and offered AV an ice pack for AV's injury. According to an investigation, at approximately 6:30 am, a picture of AV's injuries was sent to facility staff, showing AV's swollen right wrist and a baseball size bump on AV's right forehead that was dark red and purple in color that also had dried blood at AV's hairline. At approximately 11:30 am, 11 hours after AV was first observed injured, the facility notified AV's family of AV's injury and called EMS to take AV to the hospital. At the hospital, AV was diagnosed with a hematoma and fractured right wrist. The facility failed to provide services, to include timely medical treatment, change of condition and monitoring, and resident safety, resulting in prolonged unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP26-00734 $1500.00 fine assessed