Print Violation: 00353177-AP-303648

Provider Information

Farmington Square Gresham

1655 NE 18TH
Gresham, OR 97030

Date: 8/9/2024
Report number: 00353177-AP-303648
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) is a known fall risk with a history of falls while trying to self-transfer. AV is care planned for wellness checks every hour and to have a body pillow placed beside AV to reduce the risk of AV falling out of bed. On or about, August 9, 2024, AV had an unwitnessed fall, resulting in a skin tear on his/her left hand and was exhibiting dizziness, stuttering, and shaking. On or about, September 5, 2024, AV rolled to the floor from AV’s bed, resulting in AV being sent to the hospital due to hitting his/her head during the fall. It was discovered prior to AV’s first fall, that staff had not seen AV in approximately two hours and prior to the second fall, staff had not placed a body pillow beside AV prior to the fall. The facility failed to follow AV’s care plans, which is a violation of resident rights, is neglect of care which constitutes abuse.
Sanction: RCFCP25-00029 $1125.00 fine assessed