- Date
- 3/25/2025
- Report number
- 00391442-AP-342027
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Witness #1 (W1) has history of being protective of h/h room, especially when other residents go near it. W1 service plan indicates staff are to redirect others away from W1's room. Alleged Victim AV is a wanderer into other resident’s rooms and when s/he needs to use the bathroom. AV service plan indicates staff are to keep an eye on AV and redirect h/h to h/h room if s/he is in other resident’s room. On or about March 25, 2025, AV went into W1's room uninvited which upset W1, so s/he started to hit AV with h/h cane. AV had no redness, bruising or pain due to this incident. Facility failed to follow AV and W1 Care plan which is a violation of Oregon Administrative Rules.