Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00455546-AP-407691
Provider Information
Fox Hollow
5320 FOX HOLLOW RD
Eugene, OR 97405
- Provider ID
- 50R046
- Administrator
- Brandy Thomas
- Phone
- (541) 343-8439
- ed@foxhollowcare.com
Violation Details
- Date
- 2/4/2026
- Report number
- 00455546-AP-407691
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Rule(s) Violated
-
411-054-0025(1)(a) and (b)
- Findings
- Alleged Victim (AV) died by suicide while under the facility’s care and supervision. Alleged Perpetrator 2 (AP2), an employee of the facility, did not perform required safety checks despite AV being identified as a suicide risk. Documentation and interviews show that on February 2, 2026, the facility implemented a temporary safety plan after learning that AV had requested weapons and expressed intent to kill self while visiting a family home. The plan required hourly safety checks for 72 hours and restricted AV’s access to metal utensils. It was communicated to staff through a binder accessible to all employees and through verbal communication during shift changes. At the start of AP2’s shift or about February 4, 2026, multiple staff members informed AP2 of the expectation to complete hourly checks on AV. Shortly after 5:00 a.m., AV was found unresponsive with oxygen tubing around AV’s neck and was determined to be deceased. AV was cold when found, indicating AV may have been alone for longer than an hour or that more than an hour had passed since death. Staff reported that AV had been doing well prior to the start of AP2’s shift and that required checks were being completed as expected prior to the start of AP2's shift. AP2’s failure to perform the required safety checks created a risk of serious harm and is considered neglect of care, which constitutes abuse. The facility failed to provide a safe environment for AV which resulted in AV's death by suicide which is a violation of Oregon Administrative Rules.