Print Violation: 00416970-AP-368262

Provider Information

Heartwood Place

2325 BOONES FERRY ROAD
Woodburn, OR 97071

Date: 7/27/2025
Report number: 00416970-AP-368262
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
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)(c) and (g)
Findings: The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about July 27, 2025, AV was found on the floor in their apartment after an apparent fall from the wheelchair. AV's service plan, last updated July 26, 2025, did not include a risk of falls or have interventions for staff to follow to reduce the likelihood of falls. Previous fall interventions, identified in temporary service plans, had not been included in the current service plan. The facility did not develop or implement any known changes to AV's care plan following a fall on June 30, 2025. The facility failed to develop fall interventions to address AV’s fall risk, resulting in injury and a fractured right hand. The facility failed to properly plan care for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction: RCFCP26-00535 $500.00 fine assessed