Violation Details: 00438683-AP-390500

Records Request Print
Date
11/12/2025
Report number
00438683-AP-390500
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) is care planned as a two-person transfer for toileting duties. On or about November 12, 2025, Alleged Perpetrator #2 (AP2) was assisting AV with brief change and did not request another staff to assist. During the process, AV slid from the bed onto the floor. AV didn't suffer any injury, however, AV was placed at risk for harm. AP2's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The faciilty's failure to ensure the care plan was followed is a violation of Oregon Administrative Rules.