- Date
- 2/6/2026
- Report number
- 00456305-AP-408479
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about February 6, 2026, Alleged Perpetrator (AP2) failed to provide the stand-by assistance with showering as documented in Alleged Victim's (AV) care plan. Based on facility documentation and interviews, Witness 3 (W3) responded to calls for help coming from AV’s living quarters and found AV seated alone on a shower chair in the running shower without staff present. W3 then located AP2 lying asleep in AV’s bed. W3 awakened AP2 by shining a light on AP2’s face and physically shaking AP2. The facility subsequently terminated AP2’s employment for sleeping while on duty. Based on the statements of witness knowledge and investigator observations, the investigator determined that the following events happened: AP2 did not provide the required stand-by assistance to AV on February 6, 2026, which resulted in a risk of potential harm as AV required stand-by assistance for safety. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is violation of Oregon Administrative Rules.