Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00327576-AP-278953
Provider Information
Mountain Park Memory Care Community
13600 SE 122ND AVE
Clackamas, OR 97015
- Provider ID
- 50R483
- Administrator
- AMY BUCHANAN
- Phone
- (503) 919-7722
- ed@mountainparkmc.com
Violation Details
- Date
- 4/25/2024
- Report number
- 00327576-AP-278953
- 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)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(A) and (H) and (I)
External site: 411-054-0036(2)(g)
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. AV is a known wander, often forget to use h/h walker, and often wander into other resident rooms. AV's service plan dated on or about April 17, 2024, has interventions in place to ensure AV has on shoes or non-skid socks when ambulating around community. Staff are to leave bathroom or night light on during night to help AV find bathroom if AV wakes up. During NOC, staff to check that AV's walker is at bedside while AV is asleep so that walker is within reach is AV wakes up. Staff to redirect AV is seen entering another resident’s apartment. On or about April 25, 2025, AV wandered into another resident’s room and had an unwitnessed fall. AV was diagnosed with a fracture left humerus bone. Staff identify AV as a wanderer but there are no interventions provided in AV's service plan to mitigate risks associated with wandering. The facility failed to appropriately care plan around AV wandering, and failed to follow AV care plan by staff no redirecting AV when AV entered another resident’s room resulting in AV falling and fracturing h/h humerus bone.
- Sanction
- RCFCP24-01167 $1125.00 fine assessed