- Date
- 1/11/2026
- Report number
- 00450274-AP-402289
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) lived at Respondent’s facility. AV had history of refusing shower assistance. AV’s service plan reflects; AV is stand by assistance for bathing; Staff are to explain to AV that they can stand outside the door of the bathroom while AV showers to allow AV privacy and to be there for AV's safety if AV needs assistance. On or about January 11, 2026, Alleged Perpetrator #2 (AP2) was assigned to AV's section. AP2 opened AV's door at approximately 4:00am heard the shower running and walked out of AV's room. Facility staff found AV at approximately 7:30am lying on the shower floor unresponsive with the water running. AP2 failed to follow the care plan and provide stand by assistance to AV while AV was showering, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The respondent failed to ensure supervision, and quality of services rendered, which is a violation of Oregon Administrative Rules.