Print Violation: 00149175-AP-117986

Provider Information

Mountain Park Memory Care Community

13600 SE 122ND AVE
Clackamas, OR 97015

Date: 7/11/2021
Report number: 00149175-AP-117986
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025-(1)(a) and (b)
External site: 411-054-0027(1)(a)(f) and (r)
External site: 411-054-0028(2)
Findings: Alleged Victim (AV) relies on the facility for h/h care and for a safe environment. Staff are to assure all residents are inside the facility prior to locking courtyard doors at night. AV is service planned to receive safety checks at meds pass, beginning and end of shift and twice during Noc shift. With each check staff are to verify that AV is in the middle of their bed. Camera review shows on or about July 11, 2021, AV going out the door to the courtyard at approximately 8:36pm and Alleged Perpetrator #2 (AP2) going into AV’s room at approximately 9:11pm and locking the courtyard door at approximately 9:32pm. AV was found outside in the courtyard the next morning at approximately 7:11am when staff unlocked the door. AV’s feet were cold and discolored, AV had bruise to right wrist, elbow, and left shin. AP2’s actions of not visualizing AV during safety check is violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure residents rights and a safe environment was being followed, which is a violation of Oregon Administrative rules.