Violation Details: 00436929-AP-388782

Records Request Print
Date
11/2/2025
Report number
00436929-AP-388782
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)
Findings
According to the documentation, the Alleged Perpetrator 2 (AP2) did not notify facility staff that the Alleged Victim (AV) call light was going off. AV is prescribed oxygen at all times due to medical diagnosis. On or about November 02, 2025, AV used their call light to notify staff they did not have their oxygen on. AP2 did not follow facility protocol by having the large walkie on them to notify them if a call pendant was activated. The AV went approximately 40 minutes without their oxygen, placing them at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.