Print Violation: 00248668-AP-204585

Provider Information

Cedar Crest Alzheimer Special Care Center

18325 SW PACIFIC HWY
Tualatin, OR 97062

Date: 2/23/2023
Report number: 00248668-AP-204585
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(I)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) relies on the facility for h/h safety and is known to be a high elopement risk. AV knows if s/he holds down the bar on exit door for approximately 15 seconds, the door will automatically unlock and open. AV has history of eloping the facility by this method. AVs care plan indicates staff are to monitor AV with location checks, increase involvement in activities and exercise. On or about February 23, 2023, the alarm from the exit door went off, and staff found AV eloped outside in the snow placing AV at risk of serious harm. The facility failed to provide a safe environment, follow the AV care plan, and appropriately implement reasonable interventions to address AV’s exit seeking behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP23-00547 $188.00 fine assessed