Print Violation: 00433526-AP-385587

Provider Information

South Beach Manor

411 SE 35TH ST
South Beach, OR 97366

Date: 10/18/2025
Report number: 00433526-AP-385587
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. On or about October 18, 2025, care staff heard screaming and found AV pinned against a wall by W1, with W1's hands wrapped around both of AV's wrists. Staff separated AV and W1 and AV was noted to have purple discoloration of their left elbow and observable anxiety. According to an investigation, W1 had a history of being the aggressor in a separate resident to resident altercation with another resident, approximately one month before, but no additional interventions were added to W1's care plan. The facility failed to provide appropriate services, to include care planning and/or implementation of 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.
Sanction: RCFCP26-00393 $500.00 fine assessed