Print Violation: 00347103-AP-297717

Provider Information

Serenity RCF

15225 SE POWELL BLVD
Portland, OR 97236

Date: 8/3/2024
Report number: 00347103-AP-297717
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: The Alleged Victim (AV) relied on the facility for his/her care and was care planned for safety checks, line of sight monitoring while out of their bedroom, and to be accompanied by staff when leaving the facility. On or about July 17, 2024, and then again on August 3, 2024, AV left the facility at night without staff knowledge. According to an investigation, in both instances staff did not perform safety checks on AV at night and did not know AV was missing until morning. AV went out in the community and was unable to find their way back. While out on August 3, 2024, AV injured their foot trying to propel themselves all night while lost. The facility failed to follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00708 $1500.00 fine assessed