Print Violation: 00459147-AP-411395

Provider Information

Rn Villa Senior Care

401 NE 139TH AVENUE
Portland, OR 97230

Date: 12/3/2025
Report number: 00459147-AP-411395
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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) relies on the facility for assistance with repositioning and transfers. Home Health wound care services were in place and directed use of a 'slippery sheet" with handles for use when repositioning the AV to prevent shearing injuries. According to an investigation, the "slippery sheet" was not used, and the AV was identified with an open wound to the left buttock on or about December 3, 2025. The wound worsened and Home Health was contacted for treatment. On or about February 20, 2026, Home Health observed a Stage 2 shearing wound to the AV's left sacral area. The facility failed to follow the care plan, which is a violation of residents' rights, is neglect of care, and constitutes abuse.
Sanction: RCFCP26-00335 $500.00 fine assessed