Print Violation: 00067662-AP-049023

Provider Information

Skylark Assisted Living

900 SKYLARK PLACE
Ashland, OR 97520

Date: 9/12/2019
Report number: 00067662-AP-049023
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: Alleged Victim (AV) experienced approximately ten falls from February 2019 through September 2019. Interventions in place were to remind AV to use his/her pendant to call for assistance and safety checks every two-three hours. AV's service plan states AV's ingestion of CBD gummies contributed to AV's falls, team to watch for AV becoming tired and direct AV to AV's apartment. Upon investigation it is noted that AV needed assistance transferring, didn't always remember to use his her call pendant and was unable to make major life decision due to not understanding the risks, benefits and consequences of AV's choices. On or about September 12, 2019, AV fell while transferring sustaining a neck fracture and head injury. The facility failed to implement appropriate interventions to mitigate AV's risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: ALFCP20-00454 $1500.00 fine assessed