Print Violation: 00402694-AP-353609

Provider Information

Guardian Angel Homes Memory Care

540 NW 12TH ST
Hermiston, OR 97838

Date: 5/20/2025
Report number: 00402694-AP-353609
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: Alleged Victim (AV) relies on the facility for assistance with mobility, including the use of a gait belt and stand by assistance with transfers and ambulation. According to an investigation, on or about May 20, 2025, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and failed to utilize a gait belt or provide stand by assistance when transferring the AV, resulting in the AV falling. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.