Violation Details: 00445896-AP-397914

Records Request Print
Date
12/15/2025
Report number
00445896-AP-397914
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) and (s)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(I)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations and are care planned to not be sitting together during meals. On or about December 15, 2025, AV and W1 were sitting at a table together, AV reached to get a plate of desert and W1 stabbed AV in the hand with a fork, causing a scratch and bleeding to AV's knuckle. Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) were working that day and had not read the temporary service plans regarding these two residents and did not separate them. AP2 and AP3's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure the care plan was followed is a violation of Oregon Administrative Rules.