Violation Details: 00428424-AP-380100

Records Request Print
Date
9/16/2025
Report number
00428424-AP-380100
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) is care planned to be transferred with a gait belt. On or about September 16, 2025, Alleged Perpetrator #2 (AP2) transferred AV from the toilet using a bear hug type transfer, causing AV pain in his/her ribs. AV was transferred to the hospital and diagnosed with fractured ribs. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The faciilty's failure to ensure the care plan was followed is a violation of Oregon Administrative Rules.