Violation Details: 00430197-AP-382024

Records Request Print
Date
10/1/2025
Report number
00430197-AP-382024
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 a 2-person transfer and assistance with toileting. AV is care planned to not be left alone while using the toilet, due to AV being a fall risk. On or about October 1, 2025, Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) assisted AV to the toilet and then left AV's room. After about 5 minutes, AP2 and AP3 heard a thud and went into AV's room and found AV on the floor of the bathroom. AV suffered redness and bruising to his/her tailbone from the fall. AP2 and AP3's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure staff followed the care plan is a violation of Oregon Administrative Rules.