Violation Details: 00478613-AP-431554

Records Request Print
Date
5/21/2026
Report number
00478613-AP-431554
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)
411-054-0027(1)(s)
411-057-0140(1)
Findings
On or about May 21, 2026, the facility failed to adequately oversee its daily operations, resulting in insufficient safeguards to ensure resident safety which allowed Alleged Victim (AV) to elope from the secured memory care community. Based on facility documentation and staff interviews, a secured exit door was malfunctioning and did not operate as intended. As a result of this failure, the AV eloped from the secured memory care unit when the door failed to lock and close properly after use by Witness 5 (W5). The facility's failure to maintain a secure facility environment, ensuring that all exit door function properly and lock securely is a violation of Oregon Administrative Rules.