Print Violation: 00347555-AP-297951

Provider Information

Stephanie Gardens Residential Care

19751 SE STARK ST
Portland, OR 97233

Date: 8/8/2024
Report number: 00347555-AP-297951
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
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: 411-054-0036(2)(g)
External site: 411-054-0040(1)(b) and (d)
Findings: The Alleged Victim (AV) is a known fall risk and is diagnosed with a cognition disorder, has inappropriate judgement regarding his/her safety, as well as a wound on his/her foot, which causes the high risk of falls. AV is care planned to be checked on four times per day, AV's door is to be kept open for monitoring and staff are to attempt to take AV to the restroom multiple times per day. AV suffered four unwitnessed falls between July 11, 2024 and August 8, 2024 which resulted in injury. AV had a change of condition and his/her are plan was to be updated with new interventions. No new interventions were added. On or about August 8, 2024, AV suffered an unwitnessed fall, resulting in a fractured hip, requiring surgical intervention. The facility's failure to have interventions in place to assure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP25-00351 $1500.00 fine assessed