Print Violation: 00401534-AP-352428

Provider Information

Guardian Angel Homes Memory Care

540 NW 12TH ST
Hermiston, OR 97838

Date: 5/6/2025
Report number: 00401534-AP-352428
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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: 411-054-0028 (2)
External site: 411-054-0036 (2)(g)
Findings: The Alleged Victim (AV) is a fall risk, has a history of falls, and is dependent on staff to implement fall interventions. According to an investigation, on or about May 6, 2025, AP2 neglected to put the AVs fall mat at the bedside as care planned, after assisting the AV into bed. The AV was found on the floor at their bedside resulting in pain to the right hip and right side of the face. AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to ensure care plans were implemented, which violates Oregon Administrative Rules.