Print Violation: 00382624-AP-333090

Provider Information

Mountain Park Memory Care Community

13600 SE 122ND AVE
Clackamas, OR 97015

Date: 2/6/2025
Report number: 00382624-AP-333090
Type: Abuse: Neglect
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)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: On or about February 7, 2025, the Alleged Victim (AV) suffered two unwitnessed falls. AV is a known falls risk with a history of falls. AV has service plan interventions which include to use a walker, have grip socks on, safety checks, room free from clutter and frequent toileting. On this date, AV returned from the hospital sedated. AV was not placed on increased safety checks or monitoring. No interventions were placed between the first and second fall. AV's walker was not present during either fall, and AV did not have grip socks on. The facility's failure to ensure oversight, follow the care plan and ensure interventions were in place is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP25-00535 $250.00 fine assessed