- Date
- 12/31/2025
- Report number
- 00449551-AP-408694
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for care. W1 has a documented history of inappropriate sexual behavior with other residents and is care planned to be escorted any time they are outside of their room. According to an investigation, on or about December 31, 2025 AV was inappropriately touched by W1, while at a facility gathering and a again short time later when W1 and AV were in common area hallway leaving the gathering. The next day, January 1, 2026, W1 attempted to coerce AV into their room, and then sat outside AV's room for days waiting for them to enter the common area. The Alleged Perpetrator 2 (AP2) found out about the recent incidents on January 6, 2026, but failed to take any action for approximately 2 days, resulting in emotional harm for AV, as well as placing AV at risk for serious harm. The AP2 knew W1 had a history of inappropriate sexual behavior and failed to ensure staff were following the service plan and/or implement a safety plan for W1's behaviors before or after the incidents on December 31, 2025, and January 1, 2026, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure a safe environment, which is a violation of Oregon Administrative Rules.
- Sanction
- ALFCP26-00231 $1500.00 fine assessed