Violation Details: 00389223-AP-339748

Records Request Print
Date
3/3/2025
Report number
00389223-AP-339748
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: 411-054-0027(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 his/her care needs. On or about March 3, 2025, AV was found to have skin discoloration to his/her left arm and AV said the skin discoloration occurred from improper transferring by NOC shift staff. AV is a two-person transfer; however, it is believed an unknown NOC shift staff Alleged Perpetrator 2 (AP2) may have conducting oner person transfers with AV. AP2 failed to follow AV’s care plan around AV’s two-transfer, which is neglect of care and constitutes abuse. The facility failed to assure AV’s care planned was being followed, which is a violation of Oregon Administrative Rules.