Violation Details: 00443873-AP-395863

Records Request Print
Date
12/6/2025
Report number
00443873-AP-395863
Type
Abuse: Neglect
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)(g) and (s)
External site: 411-054-0028(2)(a) and (b)
External site: 411-054-0030(1)(e)(H) and (I)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) lives at Respondent’s facility. AV has a history of exit seeking behavior prior to moving into Respondent's facility. AV is known to wander, look for open doors and fidget with door handles. AV’s service plan reflected AV has a disease that causes cognitive impairment, poor safety awareness and poor judgement. However, the facility failed to develop sufficient interventions to mitigated risk to AV. On or about December 06, 2025, AV eloped from Respondent's facility. Facility staff found AV walking outside around the facility bus, and near a busy road. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(ii).
Sanction
RCFCP25-01501 $500.00 fine assessed