Violation Details: 00452359-AP-404382

Records Request Print
Date
1/21/2026
Report number
00452359-AP-404382
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide inservice
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
Findings
The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about January 21, 2026, the Alleged Perpetrator 2 (AP2) failed to use restraints properly when he/she applied a gait belt strap to AV who had a history of recent falls and was seated in a wheelchair. AP2 applied the belt with the clasp located out of reach and AV could not self-release it, resulting in AV being restrained, upset and at risk of injury. AP2's actions are considered wrongful restraint and constitutes abuse. The facility failed to provide a safe physical environment, which violates Oregon Administrative Rules.