- Date
- 7/25/2025
- Report number
- 00416920-AP-368196
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is care planned to have a commode next to his/her bed each night. On or about July 25, 2025, at 5:33 AM, AV had an unwitnessed fall. Alleged Perpetrator 2 (AP2) did not put the commode next to AV’s bed and did not do 2-hour safety check on AV. As a result of the fall, AV’s back was sore and was sent to the hospital for evaluation. AP2 failed to follow the care plan around the commode, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was followed, which is a violation of Oregon Administrative Rules.