- Date
- 3/18/2026
- Report number
- 00465649-AP-418007
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff to meet safety and care needs. AV’s service plan requires a two-person assist for transfers into a wheelchair. AV prefers to sit in the common area in an armchair with legs elevated and is able to self-direct when needing to stand, reposition, or use the bathroom. Staff are responsible for ensuring that wheelchair brakes are engaged during all transfers. It is standard safety practice that wheelchairs must be locked prior to any task involving movement or repositioning.
On March 18, 2026, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) attempted to elevate AV’s legs while AV was seated in a wheelchair. The wheelchair was not locked during this procedure, causing it to tilt backward. As a result, AV fell backward and struck their head against the wall. AP2 and AP3 had been trained on the requirement to lock a wheelchair before elevating a resident’s feet. Their failure to lock the wheelchair and to follow AV’s service plan constitutes a violation of resident rights, is considered neglect of care, and meets the definition of abuse. The facility failed to provide adequate oversight and monitoring to ensure AP2 and AP3 followed AV’s service plan and facility safety standards while providing care. This failure represents a violation of Oregon Administrative Rules.