Print Violation: 00321228-AP-273042

Provider Information

River Terrace Memory Care

950 SOUTH END RD
Oregon City, OR 97045

Date: 3/26/2024
Report number: 00321228-AP-273042
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: 411-054-0025(1)(a) and (b)
External site: 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) is a known fall risk, and their service plan states to keep AV’s walker next to them when they are in bed, remind them to use the call light when they need help, and to perform safety checks on the resident each shift. On or about March 26, 2024, AV was found on the floor in their room, from an unwitnessed fall, and stated they hit their head. According to the investigation, staff cannot recall the last time AV had a safety check prior to the fall and AV’s walker was not next to AV bed, but found approximately 35 feet from the AV’s room in the doorway to another resident’s room. It was also discovered that AV cannot remember to use their walker, despite daily reminders. The facility failed to ensure resident safety, which is a violation of resident rights is neglect of care and constitutes abuse.
Sanction: RCFCP24-00679 $375.00 fine assessed