Print Violation: 00378797-AP-329254

Provider Information

The Stafford Assisted Living Facility

1200 OVERLOOK DR
Lake Oswego, OR 97034

Date: 1/20/2025
Report number: 00378797-AP-329254
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: 411-054-0036(2)(g)
Findings: The facility failed to assess and implement appropriate interventions after the Alleged Victim (AV) experienced two balance-related incidents within three days. On or about January 17, 2025, AV lost balance during an activity, brushed against a fireplace, and reported pain. Despite AV’s known fall history, no new interventions were implemented. On or about January 20, 2025, AV fell again while putting on nonskid socks, resulting in fractured ribs. By failing to respond appropriately to the first incident, the facility allowed a preventable risk to escalate, culminating in the second fall and injury. Based on facility documentation and interviews, the facility failed to appropriately care plan by not implementing reasonable interventions to address AV's fall risk, which is a violation of resident rights, constitutes neglect of care, and is considered abuse.
Sanction: ALFCP25-00447 $375.00 fine assessed