- Date
- 7/1/2025
- Report number
- 00411226-AP-362383
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care needs. AV was taken into the restroom by Alleged Perpetrator 2 (AP2) to change pants after spilling juice on AV at the table. AV was also assisted to the toilet. AP2 reported he/she had AV hanging on to the safety bar and turned to retrieve a brief for AV. When AP2 looked back, AV had left go of the safety bar and was leaning to the side while pulling AV’s brief. It was determined via video footage that the care plan was not followed by AP2, and no gait belt was present when AV was transferred into the bathroom and was not utilized for AV’s transfer to the toilet as indicated in AV’s care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was being followed, which is a violation of Oregon Administrative Rules.