Print Violation: 00440726-AP-392747

Provider Information

Macdonald Residence

605 NW COUCH STREET
Portland, OR 97209

Date: 11/20/2025
Report number: 00440726-AP-392747
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 Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation, the AV fell on September 4, 2025, and sustained a compression fracture of the spine. Following the fall on September 4, 2025, the facility failed to implement interventions to address the root cause of the AVs falls or to mitigate the risk of future falls and injuries. The AV had another fall on or about November 20, 2025, was sent to the emergency department, diagnosed with multiple rib fractures, and admitted to the hospital Intensive Care Unit. The facility failed to provide appropriate services according to AV’s needs, relating to care planning and appropriate interventions, to mitigate the risk of injury, which is a violation of resident rights, is neglect of care, and constitutes abuse.
Sanction: ALFCP26-00177 $338.00 fine assessed