Print Violation: 00453089-AP-405202

Provider Information

The Watermark at The Pearl

1540 NW 13TH AVE
Portland, OR 97209

Date: 11/27/2025
Report number: 00453089-AP-405202
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate 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)
411-054-0055 (1)(a) and (f)
Findings: The Alleged Victim (AV) has a history of falls and relies on the facility to manage their medications. According to an investigation, the AV fell three times between November 27, 2025, and January 3, 2026, resulting in bruising, abrasions, and requiring an emergency room visit and staples to the head. The AV is prescribed a medication to reduce fluid retention. The facility failed to re-order the medication. The medication was not administered between January 8, 2026, to January 11, 2026, resulting in pain, discomfort, and requiring a hospital stay for treatment of the fluid retention. The facility failed to appropriately care plan for the AV's falls and to administer the AV's medications as ordered, which is a violation of resident’s rights, is neglect of care, and constitutes abuse
Sanction: RCFCP26-00121 $188.00 fine assessed