- Date
- 12/19/2025
- Report number
- 00446265-AP-398619
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) and Witness 1 (W1) reside in the Respondent’s facility and rely on facility staff to ensure that their basic care, safety, and supervision needs are met. AV and W1 have a history of resident-to-resident altercations and AV is known to wander throughout the facility and enter other residents’ rooms. W1 does not tolerate other residents entering W1’s personal space. W1’s service plan indicates facility staff are to redirect other residents away from W1's personal space, and interventions in place, facility staff are to lock W1's door. AV's service plan indicates facility staff are to monitor AV while AV is out walking facility hallways to keep AV from entering other residents' rooms. AV has interventions in place if AV is attempting to go into another resident's room, facility staff are to redirect, offer to walk with AV, offer AV a snack or drink, and set AV up with an activity. The facility failed to follow AV's and W1's service plan and did not take appropriate measures to mitigate risk either resident. On or about December 19, 2025, AV attempted to enter five different resident rooms in a 3-minute span, prior to entering W1 room. Facility staff heard yelling, responded, and witnessed W1 push AV, and AV fall backwards out of W1's doorway, landing on AV's bottom. The physical altercation resulted in AV complaining of pain. The Respondent failed to follow AV’s service plan and did not provide a safe environment. This constitutes abuse by neglect as defined under OAR 411-020-0002(1)(A)(i).
- Sanction
- RCFCP26-00662 $375.00 fine assessed