Violation Details: 00406281-AP-357302

Records Request Print
Date
6/7/2025
Report number
00406281-AP-357302
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to assure resident was safe
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) has a history of falls and self-transferring when it is not safe for AV and is care planned to have personal alarms in place when AV is in their room. According to an investigation o or about June 7, 2025, Alleged Perpetrator 2 (AP2) failed to ensure the alarms were activated. AV self-transferred and sustained a fall. The facility failed to assure the resident was safe, which is a violation of Oregon Administrative Rules. AP2 failed to follow AV's care plan, which is neglect of care and constitutes abuse.