Print Violation: 00398059-AP-348719

Provider Information

The Springs at Mill Creek

1201 W 10TH STREET
The Dalles, OR 97058

Date: 4/27/2025
Report number: 00398059-AP-348719
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g)
Findings: According to the documentation, the Alleged Perpetrator 2 (AP2) failed to follow the service plan for the Alleged Victim (AV) by transferring them by themselves when they are a two-person transfer. On or about April 27, 2025, the AV called for assistance to transfer. AP2 was the only care staff available. The AV was urging AP2 to transfer them, or they were going to self-transfer. Instead of waiting for assistance, AP2 transferred the AV by themselves even though they knew the AV was service planned for a two-person transfer. During the transfer, the AV received a skin tear on their forearm. The AP2 failed to follow the care plan for the AV which led to a skin tear, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.