- Date
- 12/23/2025
- Report number
- 00448654-AP-400624
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about December 23, 2025, while attempting to provide care, Alleged Perpetrator 2 (AP2) engaged in a physical struggle with Alleged Victim (AV) after AV grabbed a set of keys pinned to AP2's shirt. Based on facility documentation and interviews, instead of stepping back and requesting help from other staff as required by facility policy, AP2 forcibly removed the keys from AV's hands. AV is a resident of the facility and has a neurodegenerative disorder. As an employee of the facility, AP2 had completed the facility's required training, including instruction on how to work with residents who are resistant to care. AP2 was aware that facility's policy requires staff to disengage and seek assistance, such as using a change of face, when a resident becomes resistant. As a result of AP2's use of physical force, AV sustained significant skin tears and discoloration to both hands and wrists. During the investigation, AP2 acknowledged wrongdoing in how AP2 responded to AV’s resistance. AP2 was subsequently terminated from employment at the facility. AP2’s actions constitutes physical abuse. The facility failed to provide a safe environment by not protecting AV from AP2’s use of physical force while providing assistance with AV’s care needs. This failure is a violation of Oregon Administrative Rules.