Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00091626-AP-069219
Provider Information
Prestige Senior Living Orchard Heights Memory Care
695 ORCHARD HEIGHTS RD NW
Salem, OR 97304
- Provider ID
- 50R297
- Administrator
- Hilarie Hope
- Phone
- (503) 566-9052
- hilarie.hope@prestigecare.com
Violation Details
- Date
- 7/4/2020
- Report number
- 00091626-AP-069219
- 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: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0070(1)
- Findings
- Alleged Victim (AV) had a history of falls resulting in head injuries. Between December 24, 2019 and April 30, 2020, AV suffered eighteen (18) falls. On April 30, 2020, AV was being supervised by facility staff at all times due to balance problems. Between April 30, 2020 and June 23, 2020, AV was in a skilled nursing facility. On June 17, 2020, facility staff learned that AV continued to experience falls at the skilled nursing facility. On June 23, 2020, AV returned to the facility and the facility drafted a new service plan for AV which required staff to provide standby assistance to AV for transfers, and one-person gait belt assistance for ambulation. Between June 23, 2020 and July 4, 2020, AV fell nine (9) times. AV suffered head injuries in five (5) of those falls. The facility did not amend AV's service plan until June 30, 2020, requiring staff to check on AV at routine intervals due to AV being diagnosed with a urinary tract infection. AV fell twice on July 3, 2020 and twice on July 4, 2020. AV was sent to the emergency room after his/her second fall on July 4, 2020. AV arrived at the emergency room unresponsive, with low oxygen and was diagnosed with spinal fractures and cord compressions. AV died of July 8, 2020 after he/she was transitioned to comfort care. The facility was aware that care staff were not reviewing resident service plans at the beginning of their shifts. Care staff did not review AV's care plan dated June 23, 2020 until July 1, 2020 when two (2) staff members signed and dated indicating they have reviewed it. No other care staff reviewed AV's service plan prior to AV's last fall on July 4, 2020. The facility failed to care plan and implement appropriate interventions according to AV's fall history and the facility failed to ensure staff were trained on AV's care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP20-01153 $15000.00 fine assessed