Print Violation: 00090566-AP-068060

Provider Information

Evergreen Memory Care Community

3720 N CLAREY ST
Eugene, OR 97402

Date: 6/28/2020
Report number: 00090566-AP-068060
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: On or about June 28, 2020, the Alleged Victim (AV) was being assisted with a brief change by Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) when he/she slipped and fell, causing a cut to his/her leg. AV should have been seated on the bed while the change was occurring. The facility failed to ensure that staff were aware of the care plan changes for AV, resulting in injury to AV. An investigation determined no AP2 and AP3 wrongdoing or abuse occurred. The facility failure is a violation of resident rights, is considered neglect of are and constitutes abuse.
Sanction: RCFCP21-02455 $188.00 fine assessed