- Date
- 10/29/2024
- Report number
- 00363527-AP-313786
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. AV is care planned for toileting and transfer assistance and 30 minute to one hour safety checks. On or about October 29, 2025, the AV had an unwitnessed fall where AV sustained a left hip fracture and is not bed bound. During an investigation, it was discovered that the last time the Alleged Perpetrator #2 (AP2) checked on the AV was over two (2) hours before AV's fall. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.