- Date
- 4/16/2025
- Report number
- 00395747-AP-346435B
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to assure resident rights
- Result
- Substantiated
- Findings
- Alleged Victim (AV) self-propels in AV's wheelchair only short distances and doesn't have the strength to go longer distances due to a shoulder issue and chronic disease. On or about April 16, 2025, AV was in the dining room, rolling AV's self away from a dining table when AP2 approached AV, wheeled AV back to the dining table, and locked both left and right rear wheels of AV's wheelchair. AP2 locked AV's wheels because AV had been attempting to leave the dining area. AV's wheelchair locks are low to the ground, at the rear of the chair, with the hand mechanism just above relatively small wheels. AV is unable to operate the locks independently and has never been observed intentionally or accidentally locking the wheels. AP2 did not follow state guidelines for resident rights and no restraints, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the residents rights was being followed, which is a violation of Oregon Administrative rules.