Print Violation: 00209266-AP-169120

Provider Information

Mountain Park Memory Care Community

13600 SE 122ND AVE
Clackamas, OR 97015

Date: 7/8/2022
Report number: 00209266-AP-169120
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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: 411-054-0036(2)(g)
Findings: Alleged Victim (AV) is care planned to have h/h bed lowered to the lowest possible position. On or about July 08, 2022, Alleged Perpetrator #2(AP2) was assisting AV with daily care. AP2 left AV room and did not lower AVs bed to the lowest position which resulted in AV falling and sustaining two (2) lacerations to h/h head. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.