Print Violation: 00401278-AP-352173

Provider Information

Suttle Care and Retirement Inc

1601 SW 24TH ST
Pendleton, OR 97801

Date: 4/19/2025
Report number: 00401278-AP-352173
Type: Licensing Violation
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to assist with transfer
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) relies on the facility to assist with transfers. AV's care plan instructed staff to use a slide board for transfers. According to an investigation, on or about April 19, 2025, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not use the sliding board during a transfer, resulting in multiple spinal fractures and AV experiencing pain and unreasonable discomfort, requiring hospitalization. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the service plan was followed during the transfer, which violates Oregon Administrative Rules.