- Date
- 7/9/2025
- Report number
- 00412931-AP-364109
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Rule(s) Violated
-
- Findings
- The Alleged Victim (AV) relies on the facility for their care and is service planned for stand-by-assist for assistance with mobility. According to an investigation, on or about July 9, 2025, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan related to mobility assistance. The AV fell, resulting in AV hitting their head. 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.