Violation Details: 00442607-AP-394604

Records Request Print
Date
12/1/2025
Report number
00442607-AP-394604
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 with a gait belt. On or about December 1, 2025, Alleged Perpetrator #2 (AP2) was assisting AV with a shower. AP2 was transferring AV from the shower when AV's legs gave out and AP2 had to assist AV to the floor. AP2 did not request assistance of other staff with the transfer as care planned. AP2's actions placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure staff follow the care plan is a violation of Oregon Administrative Rules.