Violation Details: 00480347-AP-432829

Records Request Print Provider Details
Date
6/2/2026
Report number
00480347-AP-432829
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 to provide safe environment and needed care. AV is care planned to have a pressure alarm for safety due to AV's lack of safety awareness and risk of falling. Alleged Perpetrator 2 (AP2) provided care to AV and when doing this, turned off AV's pressure alarm. AV later stood up and fell and staff were not aware due to the alarm being turned off. The facility failed to follow the care plan, which is a violation of Oregon Administrative Rule. AP2 failed to follow the care plan for AV, which is neglect and constitutes abuse.