- Date
- 12/6/2025
- Report number
- 00443873-AP-397589
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) lives at Respondent’s facility. AV has a history of repeated falls with hospitalization from October 31, 2025, to November 04, 2025, prior to moving into Respondent's facility on November 14, 2025. AV's service plan reflects that AV needs help with ambulation. However, the facility failed to develop sufficient person-centered interventions to mitigate fall risk to AV. On or about November 22, 2025, AV fell and hit AV’s head on the wall, causing swelling, redness to the back of head, and an altered level of consciousness. AV was sent to the ER. AV fell again on November 22, 2025. AV had additional falls on December 03, 2025, and December 04, 2025. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP25-01501 $500.00 fine assessed