- Date
- 2/9/2026
- Report number
- 00456520-AP-408690
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) resided at the Respondent’s facility and had a known history of attempting to exit the building. AV moved into the facility on January 29, 2026. According to facility documentation and staff interviews, AV engaged in exit-seeking behavior on February 1, 2026, during which AV used a fire extinguisher in an attempt to break through an exit door. AV was subsequently transported to the hospital for treatment. On February 8, 2026, AV eloped from the Respondent’s secured memory care unit and was found in the assisted living area of the facility. It was reported that it took four to five staff members to return AV safely to the memory care unit. On February 9, 2026, AV exited the secured building without staff knowledge. Evidence shows that AV exited through a window approximately 2.5 feet above ground level, landing on his/her backside, and subsequently climbed over a fence to leave the property. The facility failed to provide supervision consistent with AV’s assessed exit-seeking care needs, allowing AV to elope from a secured environment undetected and placing him/her at risk of harm. The Respondent’s failure to develop and implement appropriate interventions and supervision is a violation of resident rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(ii).
- Sanction
- RCFCP26-00597 $375.00 fine assessed