- Date
- 1/20/2025
- Report number
- 00378474-AP-329059
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for care, is a fall risk, and although AV is independent with ambulation, AV is care planned for staff to monitor AV when ambulating. On or about January 20, 2025, at approximately 2:30 am, AV was found on the floor of another residents room, bleeding from a head wound that resulted in AV being transferred to the hospital for treatment. According to the investigation, the Alleged Perpetrator 2 (AP2) had previously been given a written warning for sleeping while on duty and when staff found AV on the floor, AP2 was asleep in a chair in an area of the facility they were not supposed to be in. The AP2 failed to provide services, to include following AV's care plan and monitoring AV for safety, 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 and that there were qualified and awake care staff , which is a violation of Oregon Administrative Rules.