Violation Details: 00465380-AP-417776

Records Request Print Provider Details
Date
3/22/2026
Report number
00465380-AP-417776
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)
411-054-0036(2)(g)
411-054-0070(1)
Findings
The Alleged Victim (AV) relied on the facility for his/her care and was care planned for 1:1 monitoring anytime they were out of their room. On or about March 22, 2026, AV left the facility unaccompanied and did not return until the next morning because they were lost and couldn’t find their way back in the dark. According to an investigation, the facility was short a caregiver and at dinner time the Alleged Perpetrator 2 (AP2), who was supposed to be 1:1 to AV, took food trays to the second floor via the elevator, letting AV out of their direct line of sight. AV noticed that staff weren't watching them, so they left the facility. AV went out in the community and was unable to find their way back until the next morning light, placing AV at risk for harm. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to provide services, to include implementation of services and appropriate staffing, placing AV at risk for harm, which is a violation of resident’s rights is neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(ii).
Sanction
RCFCP26-00710 $375.00 fine assessed