Print Violation: 00334374-AP-285391

Provider Information

Evergreen Memory Care Community

3720 N CLAREY ST
Eugene, OR 97402

Date: 5/31/2024
Report number: 00334374-AP-285391
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
Findings: The Alleged Victim (AV) has a history of falls and is known to self-transfer. AV is care planned for one-person assist for transfers and for staff to offer toileting assistance after meals. According to an investigation, on or about, May 31, 2024, Alleged Perpetrator 2 (AP2) witnessed AV going to his/her room after dinner and shutting his/her door and did not check on AV or offer toileting assistance. AV experienced an unwitnessed fall when he/she attempted to self-transfer, resulting in a laceration above the eyebrow and skin tears on each arm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.