Violation Details: 00442397-AP-394363

Records Request Print
Date
11/29/2025
Report number
00442397-AP-394363
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)
411-054-0036(2)(g)
Findings
On or about November 29, 2025, the facility failed to ensure the Alleged Victim’s (AV) toileting needs were met during the NOC shift. Facility documentation indicates that at the end of the shift, staff discovered AV saturated in a urine soaked and feces-filled brief. Although AV did not experience a negative outcome as a result of this unmet care need, the facility’s failure to ensure staff followed AV’s care plan which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.