Print Violation: 00106602-AP-081533

Provider Information

Tanner Spring Memory Care

23000 HORIZON DRIVE
West Linn, OR 97068

Date: 10/8/2020
Report number: 00106602-AP-081533
Type: Licensing Violation
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
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: Alleged Victim (AV) was care planned for one person assist with gait belt for transfers. On or about October 8, 2020, Alleged Perpetrator 2 (AP2) was providing AV with transfer assistance without the use of a gait belt. As AP2 was reaching for the doorknob, AV fell resulting in AV being transported to the hospital where he/she was diagnosed with a hip and wrist fracture. AP2 failed to follow AV care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was followed, which is a violation of Oregon Administrative Rules.