Violation Details: 00395013-AP-361471

Records Request Print
Date
4/13/2025
Report number
00395013-AP-361471
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, which includes two-person transfers and use of a gait belt. On or about April 13, 2025, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and transferred AV without a gait belt resulting in a skin injury. 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.
Sanction
RCFCP25-01176 $188.00 fine assessed