- Date
- 11/20/2025
- Report number
- 00440798-AP-392722
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim has a history of falls and required assistance with ambulation and mobility. The AV was care planned for the use of a gait belt and staff assistance while ambulating with their walker. According to an investigation, on or about November 20, 2025, Alleged Perpetrator 2 (AP2) was assisting the AV in their apartment. The AV was utilizing their walker, AP2 did not use the gait belt or provide stand by assistance. The AV fell and sustained bi-lateral pelvic fractures, a compression fracture to the neck, skin tears, and bruising. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility did not keep AV free from neglect, which is a violation of Oregon Administrative rules.