- Date
- 2/17/2026
- Report number
- 00458221-AP-410413
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relied on the facility for care, was independent with most care, and has a history of using the call light system if they need additional help. On or about February 15, 2026, AV was found on their bathroom floor with a head wound. AV was taken to the hospital where they received staples to close the wound and it was also discovered they had upper-left arm fracture. According to an investigation, for the few days before AV was found on the ground, AV had pulled their call light and asked for assistance toileting "constantly" and also asked for more pain medication than usual for arm/shoulder pain. On the day AV fell it was noted that the bathroom call light was tucked behind the grab bar and AV indicated they tried to pull it, but it was out of reach. The facility failed to provide appropriate services, to include proper care planning and/or the implementation of effective interventions, to assess AV for change of condition, as well as to ensure AV's call light was in reach and available to promote resident safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP26-00637 $500.00 fine assessed