Violation Details: 00468614-AP-420904

Records Request Print
Date
4/8/2026
Report number
00468614-AP-420904
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)(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 was care planned to have a bed and chair alarm placed underneath them to keep them safe. Staff were to ensure that alarms are working properly at the end/beginning of all shifts. According to an investigation, on or about April 8, 2026, AV experienced a fall and was found on the floor, resulting in abrasions and discoloration. Alleged Perpetrator 2 (AP2) did not follow the care plan when they did not ensure the pressure alarm was correctly placed under AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i). The facility allegedly failed to follow the care plan for the Alleged Victim, which is a violation of Oregon Administrative Rules.