Violation Details: 00456304-AP-408845

Records Request Print
Date
2/8/2026
Report number
00456304-AP-408845
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) relies on the facility for their care. AV has a history of falls and is care planned to have a chair alarm placed under AV at all times and for staff to ensure alarms are working properly at the end/beginning of all shifts. According to an investigation, on or about February 8, 2026, AV fell injuring their right hand/wrist and causing pain. AV’s safety alarm failed to alert staff when AV stood up from their recliner. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) did not follow the care plan when they did not check AV’s alarm at the beginning of their shifts. AP2 and AP3’s actions are violations of resident rights and are considered neglect of care. The facility failed to ensure AV’s care plan was followed, which is a violation of Oregon Administrative Rules.