Violation Details: 00455443-AP-407578

Records Request Print
Date
2/1/2026
Report number
00455443-AP-407578
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)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility for care and is care planned for 2-person to assist with transfers. On or about February 1, 2026, the Alleged Perpetrator 2 (AP2) failed to follow AV's care plan when they attempted to transfer AV by themselves, resulting in an assisted fall to the ground. AP2’s failure placed AV at risk for harm, is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure a safe environment, which is a failure of Oregon Administrative Rules.