Violation Details: 00399668-AP-350435

Records Request Print
Date
5/5/2025
Report number
00399668-AP-350435
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), 411-054-0027(1)(g) and (s), 411-054-0028(2), 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 care staff seated AV and W1 at least arm's length away from each other, resulting in AV experiencing unreasonable discomfort and being grabbed. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the service plan was followed, which violates Oregon Administrative Rules.