Violation Details: 00411919-AP-363053

Records Request Print
Date
7/3/2025
Report number
00411919-AP-363053
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
The Alleged Victim (AV) relies on the facility for his/her care. AV was care planned to have slippers on during transfers with sit-to-stand and two staff assisting with the transfer. According to an investigation, on or about July 3, 2025, the Alleged Perpetrator 2 (AP2) did not follow AV’s care plan during a sit to stand transfer, resulting in an injury to AV’s right foot and left forearm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the AV's care plan was followed, which is a violation of Oregon Administrative Rules.