Violation Details: 00442513-AP-394500

Records Request Print
Date
12/1/2025
Report number
00442513-AP-394500
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), (4)
External site: 411-054-0036(2)(g)
Findings
On or about December 1, 2025, the Alleged Victim (AV) exited the facility without staff knowledge. According to facility documentation and staff interviews, the AV was admitted on November 12, 2025, for respite care, with an anticipated discharge date of December 11, 2025. The AV has a diagnosed cognitive impairment and a progressive neurodegenerative disease. The care plan identifies the AV as unsafe to leave the facility independently. The AV returned to the facility the following day without signs of injury. The facility failed to provide adequate supervision consistent with the AV’s assessed needs, constituting a violation of Oregon Administrative Rules.