Print Violation: 00456304-AP-408845

Provider Information

Sunset Estates

281 SUNSET DRIVE
Ontario, OR 97914

Date: 2/8/2026
Report number: 00456304-AP-408845
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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) relies on the facility for their care. AV has a history of falls and is care planned to have a chair alarm placed under AV at all times and for staff to ensure alarms are working properly at the end/beginning of all shifts. According to an investigation, on or about February 8, 2026, AV fell injuring their right hand/wrist and causing pain. AV’s safety alarm failed to alert staff when AV stood up from their recliner. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) did not follow the care plan when they did not check AV’s alarm at the beginning of their shifts. AP2 and AP3’s actions are violations of resident rights and are considered neglect of care. The facility failed to ensure AV’s care plan was followed, which is a violation of Oregon Administrative Rules.