- Date
- 5/12/2026
- Report number
- 00476832-AP-429465
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for assistance with activities of daily living, including transfers. The AV is care planned to be transferred with the use of a mechanical lift and two staff. According to an investigation, on or about May 12, 2026, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) attempted to transfer the AV from bed into a shower chair without using the mechanical lift. The AV resisted the transfer and was returned to the bed. On May 13, the AV was complaining of pain and had bruising to the left lower leg. The AV was sent to the emergency department and found to have a fractured tibia. AP2 and AP3 failed to follow the AV's service plan, which is a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to ensure the AV's care plan was followed, which violates Oregon Administrative Rules. The Allegation that AP3 failed to report possible abuse or neglect was investigated and found to be unsubstantiated.