- Date
- 1/27/2026
- Report number
- 00454295-AP-406378
- 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 needs. On or about January 27, 2026, at 8:25 PM, AV was being toileted by Alleged Perpetrator 2 (AP2), who did not use a gait belt to assist with the transfer back to AV's mobility device after finishing the task. As AP2 turned around to grab something behind AP2, AV fell backwards and hit AV's head on the floor. AP2 was retrained on transfers and gait belt usage and served a suspension day for not following AV's service plan. AP2 knew AV needed a gait belt for toileting transfers, however, AP2 acknowledged not using the gait belt. AP2 failed to follow the care plan around transfer for AV, which is neglect of care and constitutes abuse. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules.