Violation Details: 00471141-AP-423474

Records Request Print
Date
4/18/2026
Report number
00471141-AP-423474
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)
Findings
Alleged Victim’s (AV’s) care plan indicates AV is a minced moist with gravy and nectar thick liquids died. Care plan also notes that staff are to watch AV while eating and remind AV to eat slowly. On or about April 18, 2026, Alleged Perpetrator 2 (AP2) gave AV half a peanut butter and jelly sandwich and left AV unattended. As a result, AV began to chock and sent to the ER. AP2 failed to assure AV’s care plan was followed, which 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.