Violation Details: 00464256-AP-416571

Records Request Print
Date
3/14/2026
Report number
00464256-AP-416571
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is a resident and relies on the facility to meet his/her daily needs. According to an investigation, on or about March 14, 2026, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when AP2 was having difficulty walking due to weakness and AP2 did not use a gait belt, resulting in AV falling in the bathroom and fracturing his/her fibula. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the service plan was followed, which violates Oregon Administrative Rules.