Print Violation: 00136595-AP-107336

Provider Information

Guardian Angel Homes Memory Care

540 NW 12TH ST
Hermiston, OR 97838

Date: 4/21/2021
Report number: 00136595-AP-107336
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: 411-054-0036(2)(g)
External site: 411-054-0040(1)(a) and (d)
Findings: Alleged Victim (AV) suffered a fall in the common area of the facility. An investigation determined that AV was seated and got up to walk away and tripped over his/her own feet and landed on his/her left side. AV recently had a change in medication dosage in which AV's PCP advised staff that the dosage change would likely lead to an increase in falls while getting the correct dosage. The facility failed to properly care plan for AV's potential risk for falls due to a change in medication dosage. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP21-03181 $1125.00 fine assessed