- Date
- 4/8/2025
- Report number
- 00394368-AP-345056
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- According to the documentation, the Alleged Perpetrator 2 (AP2) failed to follow the care plan to have two people assist with transferring the Alleged Victim (AV) which led to injury. On or about April 08, 2024, AP2 transferred the AV by themselves when they are care planned for two person transfer due to medical history. The AV sustained a skin tear due to the AP2 transferring the AV by themselves into the shower chair, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.