- Date
- 3/11/2025
- Report number
- 00388563-AP-339059
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is a resident of a memory care facility and relies on facility staff to ensure basic care, safety and supervision needs are met. AV has a history of falls and has fall intervention to place a fall mat at AV's bedside whenever AV is in bed. On or about March 11, 2025 AV fell,sustained a head injury, and was transported to the emergency room. AV was treated for a head injury and facial lacerations. Alleged Perpetrator 2 (AP2) reported the faciity was short staffed that night and did not place the fall mat at AV's bedside when AV was put into bed. The fall mat was found under AV's bed when AV was found on the floor. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to provide a safe environment, and oversight which resulted in the Alleged Victim (AV) sustaining injury from a fall. The failure is a violation of Oregon Administrative Rules.