Violation Details: 00435507-AP-387609

Records Request Print
Date
10/28/2025
Report number
00435507-AP-387609
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)
Findings
The Alleged Victim (AV) relies on the facility for care and services. According to an investigation, Alleged Perpetrator 2 (AP2) used a gait belt to transfer AV, which is not in AV's care plan. The facility had told AP2 that they do not use gait belts, but AP2 continued to use them resulting in AV getting bruised. The facility allegedly failed to follow the care plan. An investigation determined the allegation to be inconclusive. The allegation that AP2 neglected AV was investigated and determined to be substantiated. This is a violation of Oregon Administrative Rule.