Violation Details: 00487764-AP-440403

Records Request Print
Date
7/1/2026
Report number
00487764-AP-440403
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)
411-054-0030(1)(e)(A) and (I)
Findings
The Alleged Victim (AV) is a known fall risk and is known to attempt to stand up on his/her own. AV is care planned to have supervision at all times, a staff member is to be in the west hall at all times for resident safety. On or about July 2, 2026, AV suffered a fall where he/she suffered abrasions to his/her eyebrow. AP2 was not in the west hall as determined by the contract, but was over in another hall assisting another staff member with other residents. AP2 knew that he/she was to have coverage to leave his/her post and did not request coverage before leaving, which left AV at risk for harm. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes abuse as outlined in OAR 411-020-0002(1)(b)(A)(ii). The respondent's failure to ensure staff followed internal procedure to assure resident safety is a violation of Oregon Administrative Rules.