Violation Details: 00428816-AP-380526

Records Request Print
Date
9/24/2025
Report number
00428816-AP-380526
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)(a),(g), and (h)
Findings
On or about September 24, 2025, Alleged Perpetrator 2 (AP2) failed to provide a safe environment for Alleged Victim (AV) when AP2 forcefully grabbed AV’s arm while assisting AV with transferring. AP continued to treat AV roughly despite AV stating that AP2’s actions were causing pain, resulting in unreasonable physical discomfort. AV is a resident of the facility and relies on facility staff to provide safe and adequate care. AP2 had received all required training necessary to work at facility in a caregiver position. After incident, AV was observed with visible skin discoloration on both the right and left arms and reported that AP2 caused pain during the transfer on the date of the incident. AP2’s actions constitute neglect of care, which meets the definition of abuse. The facility’s failure to ensure a safe environment for AV represents a violation of Oregon Administrative Rules.