Violation Details: 00439187-AP-390995A

Records Request Print
Date
9/15/2025
Report number
00439187-AP-390995A
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility to meet his/her daily needs and was care-planned as being at risk for falls. According to an investigation, on or about September 15, 2025, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when leaving AV on the toilet and closing the door, resulting in AV being exposed to potential harm. AP2's actions are considered neglect and constitute abuse. The facility failed to provide a safe environment, which violates Oregon Administrative Rules.