Violation Details: 00440707-AP-392623

Records Request Print
Date
11/20/2025
Report number
00440707-AP-392623
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to answer call light in a timely manner
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: 411-054-0028(2)(a) and (b)
External site: 411-054-0030(1)(e)(A) and (G)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) lives at Respondent’s facility. AV is a high fall risk and has history of falls. AV's service plan reflects AV experiences frequent urges to urinate and often calls for assistance. AV requires and escort with AV’s wheelchair and 1 person assist with a gait belt for transfers to and from the toilet. Facility staff expectation is for all call lights to be answered within 5-7 minutes. On or about November 20, 2025, AV called for assistance at 7:46pm, AV was found by facility staff on the floor at approximately 8:19pm. AV experienced a fall due to attempting to utilize the restroom on AV’s own as a result of waiting to long for assistance from Alleged Perpetrator 2 (AP2). AP2 failed to answer the call light in a timely manner, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Respondent failed to ensure AVs needs were met which is a violation of Oregon Administrative rules.