Violation Details: 00472754-AP-425079

Records Request Print
Date
4/25/2026
Report number
00472754-AP-425079
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 providing care and services. On 04/25/2026, Alleged Perpetrator 2 (AP2) was providing care for AV in bed and AP2 pulled AV's bed away from the wall. AV then fell out of the bed between the wall and the bed, sustaining a head injury. Moving the bed away from the wall was not part of AV's care plan. The facility failed to follow the care plan for AV, which is a violation of Oregon Administrative Rule. AP2 failed to follow AV's care plan, which is a violation of resident rights, is neglect and constitutes abuse.