Print Violation: 00108317-AP-083077

Provider Information

River Terrace Memory Care

950 SOUTH END RD
Oregon City, OR 97045

Date: 10/20/2020
Report number: 00108317-AP-083077
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(G)
External site: 411-054-0036(2)(g)
Findings: On or about October 6, 2020, Alleged Victim (AV) moved into the facility and his/her initial assessment indicated that he/she was mostly independent with toileting and could alert staff when he/she needed to toilet or to be changed. Staff state it became clear early on that AV was not independent with toileting but was actually incontinent and unable to convey toileting needs to staff. On or about October 20, 2020, AV was found in a saturated, breaking-down brief, indicating he/she had been changed for a long while, and removing the brief caused AV discomfort and loss of dignity. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) assisted AV before and after dinner. Neither AP2 nor AP3 checked AV's toileting needs. AP2 and AP3 failed to provide care when the expectation existed which is neglect of care and constitutes abuse. The facility failed to update AV's care plan to meet AV's toileting needs, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP21-01995 $250.00 fine assessed