Violation Details: 00452650-AP-404700

Records Request Print
Date
1/11/2026
Report number
00452650-AP-404700
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: 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) had an alert regarding wounds to his/her ankles and was care planned on January 8, 2026, to have daily wound care and bandage changes. On or about January 7, 2026, and January 8, 2026, Alleged Perpetrator #2 (AP2) documented that AV's wounds were healing and looked good. On January 8, 2026, staff witnessed AV having the same bandage dated January 5, 2026. On January 9, 2026, AP2 completed wound care for AV's ankles. On January 11, 2026, AV was observed to have the same bandages on his/her ankles from January 9, 2026. On or about January 11, 2026, AV was transferred to the emergency department for pain and signs of infection involving his/her ankles. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure staff followed directions for wound care is a violation of Oregon Administrative Rules.