Violation Details: 00482279-AP-434892

Records Request Print
Date
6/9/2026
Report number
00482279-AP-434892
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)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility for their care. AV is care planned for Staff to ensure that the fall mat is in place by his/her bed while AV is in bed and a pressure pad to be positioned correctly under them. According to an investigation, AV experienced a fall on or about June 9, 2026, resulting in a laceration to AV’s forearm and bruising to their elbow. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) did not follow AV’s care plan. AP2 and AP3’s actions are considered neglect of care which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).