Violation Details: 00468948-AP-421285

Records Request Print
Date
4/8/2026
Report number
00468948-AP-421285
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)
Findings
The Alleged Victim (AV) relies on the facility for their care. The AV had an order to have dressing changed by facility staff on Saturday. According to an investigation, Alleged Perpetrator 2 (AP2) did not change AV’s dressing, but marked that they did. As a result, AV went for approximately four days without their dressing being changed causing AV’s wound to smell and increase in size. AV was transported to urgent care and prescribed two different types of antibiotics for the infected wound. AP2’s action is considered neglect of care, which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i). The facility failed to ensure the care plan was followed, which is a violation of Oregon Administrative Rules.