Print Violation: 00346207-AP-296647

Provider Information

Guardian Angel Homes Memory Care

540 NW 12TH ST
Hermiston, OR 97838

Date: 8/4/2024
Report number: 00346207-AP-296647
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0030(e)(A), (H) and (I)
External site: 411-054-0036(2)(b), (c), (e), and (g)
Findings: Alleged Victim (AV) relies on the facility for h/h care. AV has a history of falls. Hospice provided an alarm for AV's bed on or about July 8, 2024. According to AVs care plan, AV is supposed have the the alarm under h/h at all times, bed, wheelchair and recliner. On or about August 4, 2024, Alleged Perpetrator 2 and 3, toileted AV, and placed AV in a recliner in the living room. According to AP1 the camera video footage was viewed, which showed AV trying to get up, and s/he fell to h/h side/back and possibly bumped the back of h/h head. AP2 and AP3 did not take AV's pressure alarm from h/h apartment and did not place the alarm back under AV in the living room. AP2 and AP3 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.
Sanction: RCFCP25-00878 $375.00 fine assessed