Print Violation: 00451490-AP-403512

Provider Information

Hillside Place Memory Care

1400 SE 19TH ST
Lincoln City, OR 97367

Date: 1/11/2026
Report number: 00451490-AP-403512
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)(g)
Findings: Alleged Victim (AV) relied on the facility for his/her care and is care planned for a one person assist with ambulation and toileting. On or about January 11, 2026, the Alleged Perpetrator #2 (AP2) assisted AV to the toilet and while ambulating out of the bathroom, in the bathroom doorway, AV fell resulting in a fractured femur. According to an investigation, AV's care plan stated AV was a one person assist while using their walker, but then also said AV was unable to use their walker. AV recently received a commode for toileting, but the care plan encouraged staff to help AV walk to the bathroom for toileting. Progress Notes indicated that since October 2025, AV needed assistance from 2 people for transferring. Facility staff were unsure and inconsistent with interpreting AV's care needs based on the care plan contradictions. The allegation that AP2 failed to follow AV's care plan was investigated and was inconclusive. The facility failed to properly care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00640 $500.00 fine assessed