Print Violation: 00138660-AP-109128

Provider Information

Compass Rose Memory Care

2690 NE YACHT AVE
Lincoln City, OR 97367

Date: 5/4/2021
Report number: 00138660-AP-109128
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious 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)
Findings: Alleged Victim (AV) has a known history of falls. Between February 11th through April 22nd, 2021, AV had sustained four (4) falls. AV had experienced an unsteady gait due to side effects of medications. On or about May 4, 2021, AV sustained a fall in his/her room. Witness 2 (W2) heard AV start to fall and witnessed AV fall to the floor but did not have time to assist AV. On or about May 6, 2021, AV was complaining of severe pain and was transported to the emergency room. AV was diagnosed with a fracture to his/her spine. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP22-00174 $1500.00 fine assessed