- Date
- 5/20/2025
- Report number
- 00402694-AP-353609
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for assistance with mobility, including the use of a gait belt and stand by assistance with transfers and ambulation. According to an investigation, on or about May 20, 2025, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and failed to utilize a gait belt or provide stand by assistance when transferring the AV, resulting in the AV falling. 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.