Violation Details: 00408173-AP-359210

Records Request Print
Date
6/15/2025
Report number
00408173-AP-359210
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0030(1)(e)(H) and (I)
External site: 411-054-0200(11)(b) and (c)
Findings
Alleged Victim (AV) is a resident of a locked memory care facility. AV experiences significant cognitive impairment and relies on AP1 to manage AV's daily care needs. AV does not have a history on wandering. On or about June 15, 2025, AV was found by staff standing next to the dumpsters outside of AP1 after lunch time. It was determined that the gate was not fully latched, and the gate alarms were turned off. AV was placed on alert, a TSP was implemented, and AV's family was notified. AV sustained no injury and was last seen five minutes prior to the elopement. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.