- Date
- 9/9/2025
- Report number
- 00425363-AP-377125
- 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 his/her care. AV’s care plan notes staff are to lock AV’s wheelchair brakes while at the dining table. Alleged Perpetrator 2 (AP2) signed and reviewed AV’s care plan. AV sustained a fall from his/her wheelchair as a result of AP2 not locking the brakes on AV’s wheelchair. AP2 failed to follow AV’s care plan, which is neglect of care and constitutes abuse. The facility failed to assure AV’s care plan was followed, which is a violation of Oregon Administrative Rules.