Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00228988-AP-187099
Provider Information
Brookdale Troutdale
1201 SW CHERRY PARK ROAD
Troutdale, OR 97060
- Provider ID
- 50A236
- Administrator
- MELISSA ZENTZ
- Phone
- (503) 465-8104
- melzen@brookdale.com
Violation Details
- Date
- 10/31/2022
- Report number
- 00228988-AP-187099
- 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)(g) and (s)
External site: 411-054-0028
External site: 411-054-0036(2)(g)
- Findings
- According to the documentation, the facility failed to properly care plan for the Alleged Victim’s (AV) pressure sores which caused them to worsen. On or about July 15, 2022, Hospice services started for a left heel pressure wound. On or about September 1, 2022, a new heel wound was found on the AV’s left heel. After the new wound developed, Hospice advised the facility staff to have the AV’s heels floated at all times using a pillow or wedge, to wear protective booties at all times, to transfer by means of not allowing pressure to be put on their feet and to not let their feet rest on the floor to ensure no pressure is put on their feet. According to staff interviews, staff stated they used a stand and pivot transfer for the AV, they did not always float the AV’s heels using a pillow or foam wedge and have the AV’s feet rest on the floor while wearing the protective booties. On or about October 17, 2022, a new pressure wound was discovered on the AV’s right heel. By the end of October, AV’s left, and right heel wounds deteriorated and went to the bone causing prolonged pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00705 $2500.00 fine assessed