Print Violation: 00431964-AP-383776

Provider Information

Compass Rose Memory Care

2690 NE YACHT AVE
Lincoln City, OR 97367

Date: 8/23/2025
Report number: 00431964-AP-383776
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)(a) and (b)
External site: 411-054-0030(1)(e)
External site: 411-054-0036(2)(g)
Findings: Alleged Victim (AV) resides in the Respondent’s facility and depends on the facility staff to provide appropriate supervision and care. AV has a documented history of falls, including approximately eight falls between July 2025 and August 2025. According to AV’s service plan, AV requires standby assistance with bathing but is independent with dressing, grooming, toileting, transfers, and mobility. Despite this, the respondent failed to develop adequate interventions to mitigate AV’s ongoing fall risk. On or about August 23, 2025, facility staff heard AV screaming and found AV on the floor with a wet area beneath AV, and AV had a bleeding toenail on the right foot. The Respondent failed to develop and implement appropriate interventions to address AV’s continued fall risk. This failure constitutes abuse by neglect.
Sanction: RCFCP26-00379 $500.00 fine assessed