- Date
- 1/11/2026
- Report number
- 00450474-AP-402418
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) lives at Respondent’s facility. AV has infrequent falls, but had two falls recently, prior to this incident. AV’s service plan reflects facility staff need to use a gait belt when walking with AV. On or about January 11, 26, Alleged Perpetrator 2 (AP2) notified Witness 3 (W3) AV lost AV's balance in the day room while AP2 was ambulating AV to the dining room table for dinner resulting in AV hitting AV's head on the floor, AP2 did not have a gait belt on AV. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The Respondent failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.