- Date
- 5/21/2026
- Report number
- 00478940-AP-431404
- 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) is service planned for stand by assistance with ambulation. According to an investigation, on or about May 21, 2026, the Alleged Perpetrator 2 (AP2) assisted the AV to stand. The AP2 did not provide stand by assistance for the AV and directed in their service plan. The AV ambulated independently, falling and fracturing their clavicle, hip, three ribs, and puncturing a lung. AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. the facility did not keep AV free from neglect which is a violation of Oregon Administrative rules.