Print Violation: 00311447-AP-263980

Provider Information

Rose Schnitzer Manor

6140 SW BOUNDARY ST
Portland, OR 97221

Date: 2/5/2024
Report number: 00311447-AP-263980
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0040(1)(d)(A) and (B)
Findings: The Alleged Victim (AV) resides at the facility and has a history of falls. According to an investigation, on or about February 5, 2024, AV fell in their apartment. AV's service planned interventions were for AV to use a walker for ambulation and use of a call light when AV felt weak to receive assistance from staff. AV had falls on 9/22/23 and 1/12/24. The facility did not develop or implement any known changes to AV's care plan following the falls. The facility failed to develop fall interventions to address AV’s fall risk, resulting in a compression fracture, loss of mobility and required licensed professional intervention. The facility failed to properly care plan for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction: ALFCP25-00163 $375.00 fine assessed