Violation Details: 00427839-AP-379518

Records Request Print
Date
9/18/2025
Report number
00427839-AP-379518
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), 411-054-0027(1)(g) and (s), 411-054-0028(2)
Findings
The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about September 18, 2025, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not attach the leg pegs to AV's wheelchair during use, resulting in AV experiencing a fall with head injury. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure a safe environment, which violates Oregon Administrative Rules.