Print Violation: 00324856-AP-276721

Provider Information

Serenity RCF

15225 SE POWELL BLVD
Portland, OR 97236

Date: 4/14/2024
Report number: 00324856-AP-276721
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0030(1)(e)(I), 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) relies on the facility for his/her care. AV and Witness 7 (W7) have a history of resident-to-resident altercations and are care planned to be monitored and redirected by staff when in common spaces. Care staff do not have effective interventions to redirect W7. According to an investigation, on or about April 14, 2024, AV and W7 were in the dining room when AV started calling W7 derogatory names. W7 threw a chair at AV and both residents were threatening to kill each other. About 30 minutes later in the dining room, AV called W7 another derogatory name at which point W7 grabbed AV's walker and threw it to the ground. AV then threw hot coffee on W7. Staff then left W7 unsupervised when another altercation started, resulting in AV falling into the doorframe and then the floor, hitting AV's head requiring transport to the hospital for treatment. The facility failed to provide a safe environment and properly plan care to address behaviors, which is a violation of resident’s rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00391 $188.00 fine assessed