Violation Details: 00398902-AP-349606

Records Request Print Provider Details
Date
4/21/2025
Report number
00398902-AP-349606
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
Findings
The Alleged Victim (AV) relies on the facility to provide care and services. According to an investigation, on or about April 21, 2025, facility staff found AV on the floor next to the bed with their legs wrapped in a blanket. The care plan for AV when AV was in bed, AV should have a fall mat next to their bed. The Alleged Perpetrator 2 (AP2) failed to follow the care plan for AV, and the fall mat was not placed next to the bed when AP2 had assisted AV to bed. AP2's actions are a violation of resident rights, consider neglect and constitutes abuse. The facility failed to ensure that AV's care plan was followed, which violates Oregon Administrative rules.