Violation Details: 00423864-AP-375333A

Records Request Print
Date
8/21/2025
Report number
00423864-AP-375333A
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)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) requires hands on assistance with transfers and ambulation, and is considered a high fall risk. On or about August 20, 2025, Alleged Perpetrator #2 (AP2) was observed not using AV's gait belt as required. AV was uncomfortable and advised AP2 that it was unsafe. AP2's failure to follow AV's care plan placed AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure staff follow the care plan is a violation of Oregon Administrative Rules.