- Date
- 7/11/2025
- Report number
- 00413594-AP-364773
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care needs. On or about July 11, 2025, AV was being escorted by Alleged Perpetrator 2 (AP2) in AV’s wheelchair. While passing through a doorway, AV’s wheelchair bumped over the threshold and AV was sent forward out of the chair, hitting the ground. Although it is though that this incident was accidental, AV’s injuries could have been prevented if AP2 had properly responded to AP2’s own assessment of AV’s position in the chair before tipping the chair forward. AP2 failed to provide a safe environment for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe environment for AV, which is a violation of Oregon Administrative Rules.