- Date
- 4/16/2025
- Report number
- 00395613-AP-346310
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for their care, has a history of falls, and is care planned for safety checks. On or about May 16, 2025, the Alleged Perpetrator 2 (AP2) did not follow the AV's care plan and neglected to do safety checks during the overnight shift, placing the AV at risk of harm. The AV was found on the floor at their bedside at 5:30 am. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.