Print Violation: 00308520-AP-261266

Provider Information

River Terrace Memory Care

950 SOUTH END RD
Oregon City, OR 97045

Date: 1/22/2024
Report number: 00308520-AP-261266
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) relies on the facility for his/her care. The Alleged Victim (AV) is a known fall risk with a history of falls. AV was care planned to remind AV to use walker and that it is within reach. According to an investigation, on or about January 22, 2024, AV was found on floor by his/her apartment, resulting in a head injury. AV’s walker was approximately three to four feet away from AV. On or about January 26, 2024, staff escorted AV from the common area to AV’s apartment where AV started looking for a personal item and started to fall. Staff stepped in and prevented AV from falling, but when staff went to retrieve AV’s personal item from the common area AV fell and was found on the ground crying in pain. AV’s walker was two to three feet away from AV. The facility failed to follow AV’s care plan, which is a violation of resident rights, is neglect of care which constitutes abuse.
Sanction: RCFCP25-00161 $1125.00 fine assessed