Violation Details: 00465012-AP-417338

Records Request Print
Date
11/8/2025
Report number
00465012-AP-417338
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide service
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(I)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) and Witness 1 (W1) both relied on the facility for care. W1 had a history of aggressive behaviors, sometimes brought on by uncontrolled pain, that often led to both verbal and physical altercations. According to an investigation, on or about November 8, 2025, AV and W1 were at the dining table when W1 grabbed AV by the head and pushed AV down on the table, shattering a glass and placing AV at risk for harm. The facility failed to provide appropriate services, to include implementing effective interventions to address W1's behaviors and provide a safe environment for AV, 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)(ii).
Sanction
RCFCP26-00591 $500.00 fine assessed