- Date
- 10/16/2025
- Report number
- 00433229-AP-385133
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) has a history of falls. On or about October 16, 2025, AV experienced a fall in his/her room. Staff checked AV for injury and returned AV to his/her bed and AV fell asleep. Staff are trained to check vitals after an incident with a resident. Alleged Perpetrator #2 (AP2) did not take AV's vitals after this incident, placing AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse, as outlined in OAR 411-020-0002(1)(b)(A)(ii). The facility's failure to ensure staff take resident vitals as trained is a violation of Oregon Administrative Rules.