- Date
- 5/6/2025
- Report number
- 00401534-AP-352428
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is a fall risk, has a history of falls, and is dependent on staff to implement fall interventions. According to an investigation, on or about May 6, 2025, AP2 neglected to put the AVs fall mat at the bedside as care planned, after assisting the AV into bed. The AV was found on the floor at their bedside resulting in pain to the right hip and right side of the face. AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to ensure care plans were implemented, which violates Oregon Administrative Rules.