Violation Details: 00481851-AP-434424

Records Request Print
Date
6/6/2026
Report number
00481851-AP-434424
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) is a two person assist. On or about June 6, 2026, AV sustained a fall in his/her room. AV said, “Alleged Perpetrator 2 (AP2) was rolling me and AP2 put me to close to the edge.” AP2 moved AV to the left side of the bed and rolled AV onto AV’s left side so AP2 could apply barrier cream to AV’s buttocks. When AP2 got to the right side of the bed, AV rolled and fell off the left side of the bed onto the ground. As a result of the fall, AV sustained a fracture on AV’s right arm. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to ensure AV’s care plan was being followed, which is a violation of Oregon Administrative Rules.