- Date
- 1/25/2026
- Report number
- 00465147-AP-430060
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) resides in the Respondent’s facility and relies on facility staff to ensure that AV’s basic care, safety, and supervision needs are met. AV has poor recent memory, requires assistance with complex decision-making, and has a history of falls, including approximately five falls between September 2025 through December 2025, and one on January 25, 2026. Several of these incidents resulted in pain and required evaluation or transport by EMS. AV’s service plan indicates that AV is independent with ambulation using AV’s cane and utilizes a scooter for longer distances. Fall interventions include signs posted in AV’s room instructing AV to call for assistance; reminders for AV to contact staff to turn off lights and to request staff assistance with cleaning the kitchen; use of an assistive device to retrieve items from the floor rather than bending over; and encouraging AV to sit in a chair when putting items away. On or about January 27, 2026, facility staff found AV unresponsive on the floor halfway out of the shower with the water running. EMS transported AV for evaluation. The Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- ALFCP26-00268 $500.00 fine assessed