- Date
- 5/18/2026
- Report number
- 00477648-AP-430107
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) had a TSP in place due to fall risk. On or about May 18, 2026, AV was observed sitting in the dining area chair at the table when AV attempted to stand independently. AV leaned too far forward, causing AV to lose AV’s balance and stumble, landing on AV’s hands and knees before rolling onto AV’s left side. Alleged Perpetrator 3 (AP3) and Alleged Perpetrator 2 (AP2) didn't read or sign TSP that morning for AV which could have helped prevent this fall. Fall was due to AP2 and AP3 not following TSP that was put in place to notify care staff of self-transfer. AP2 and AP3 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to ensure the care plan was followed, which is a violation of Oregon Administrative Rules.