Print Violation: 00120680-AP-093649

Provider Information

Terwilliger Terrace ALF

2425 SW 6TH AVENUE
Portland, OR 97201

Date: 7/3/2020
Report number: 00120680-AP-093649
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(H)
External site: 411-054-0036(2)(g)
Findings: On or about late October 2019, the Alleged Victim (AV) moved into the facility and did not have a significant fall history. Over the following month, AV continued to have falls, some precautions were put into place, however, each assessment did not have any significant changes preventing AV from having more falls. On or about July 3, 2020, AV suffered a fall while attempting to self-transfer, was transported to the hospital and diagnosed with a fractured hip. The facility's failure to properly care plan to ensure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP21-01726 $2450.00 fine assessed