Violation Details: 00399589-AP-350346

Records Request Print
Date
5/3/2025
Report number
00399589-AP-350346
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide inservice
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about May 3, 2025, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not ensure a pressure pad alarm was properly working and in place, resulting in AV experiencing a fall with injury to the elbow. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the care plan was followed, which violates Oregon Administrative Rules.