- Date
- 1/25/2026
- Report number
- 00465147-AP-430067
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff to meet AV’s basic care, safety, and supervision needs. AV has poor recent memory, requires assistance with complex decision-making, and has a history of falls, including two prior incidents in January 2026 and February 2026 in which AV fell in the shower. AV’s service plan indicates, AV is independent with ambulation using a cane. Fall interventions include posting signs in AV’s room to call for assistance, use of an assistive device to retrieve items from the floor, encourage AV to sit in a chair when putting items away, staff to stand by for safety during showers as allowed by AV, provide AV with a shower bench to sit on while drying off outside the shower. On or about February 27, 2026, AV took a shower at approximately 1350 hours. When staff checked on AV at approximately 1610 hours, AV was back in the shower. Staff subsequently checked on AV at approximately 1710 hours and 1810 hours and AV was still in the shower. At approximately 1835 hours, staff found AV sitting on a chair that had fallen backward, with AV positioned on AV’s back and AV’s head against the wall. AV was transported to the hospital and diagnosed with a head injury and strained neck muscles. 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