Print Violation: 00421031-AP-372434

Provider Information

Oak Lane Residential Care Facility

727 SW ROGUE RIVER AVENUE
Grants Pass, OR 97526

Date: 8/17/2025
Report number: 00421031-AP-372434
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: 411-054-0030(1)(e)(I)
External site: 411-054-0036(2)(g)
Findings: On August 19, 2025, ODHS Adult Protective Services (APS) initiated investigation #00421031 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) and Witness 1 (W1) live at facility. Based upon the witness statements, investigators observations, and documentary evidence, on or about August 17, 2025, AV and W1 were involved in a physical altercation resulting in AV sustaining a skin injury. Both AV and W1 rely on facility staff for basic care needs due to diminished cognitive capacity. W1’s care plan requires one-on-one caregiving in common areas, meaning caregivers must remain within arm’s reach to redirect W1 and mitigate risk due to ongoing physical behaviors. Based on the preponderance of evidence, the APS Investigator determined AP2 and AP3 failed to provide required supervision for W1, resulting in harm to AV. AP2's and AP3's actions are considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.