Violation Details: 00452872-AP-404987

Records Request Print
Date
1/16/2026
Report number
00452872-AP-404987
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to assure resident was safe
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)(a) and (b)
411-054-0030(1)(e)(A), (B) and (D)
411-054-0036(2)(g)
Findings
Alleged Victim (AV) resides in the Respondent’s facility and relies on staff for assistance with daily care needs and personal safety. AV has a documented history of falls due to impaired mobility and decreased safety awareness. The established care plan directs staff to provide mobility assistance and hands-on support during showering to mitigate fall risk. On or about January 16, 2026, Alleged Perpetrator 2 (AP2) left AV unattended in the bathroom for several minutes to retrieve clothing. AP2 reported hearing a fall, returned to the bathroom, and found AV on the floor complaining of head pain. AP2’s actions violated AV’s resident rights, constitute neglect of care, and meet the definition of abuse. The facility failed to maintain a safe environment for AV, resulting in a violation of Oregon Administrative Rules.