Violation Details: 00470963-AP-423305

Records Request Print
Date
4/17/2026
Report number
00470963-AP-423305
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings
Alleged Victim (AV) has a known allergy to coconut, per AV’s care plan. On or about April 17, 2026, a cookie that contained coconut was placed on AV's meal tray by Alleged Perpetrator 2 (AP2). As a result, AV had an allergic reacting, his/her throat closed and AV could “barely breath.” ESM was called and AV was transported to the ER. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure AV’s care plan was followed, which is a violation of Oregon Administrative Rules.