- Date
- 11/11/2025
- Report number
- 00438718-AP-390526
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is care planned as a two-person transfer with a Hoyer lift. On or about November 11, 2025, AV requested Alleged Perpetrator #2 (AP2) to transfer AV from their wheelchair to use the bathroom. AV insisted the transfer happen immediately. AP2 chose to transfer AV by themselves, and during the transfer, AV fell and hit the back of their head. AV was transported to the hospital for evaluation. AV returned with only a bump to his/her head. AP2's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure the care plan was followed is a violation of Oregon Administrative Rules.