Print Violation: 00117107-AP-090605

Provider Information

Jefferson Lodge Memory Care Community

664 SE JEFFERSON ST
Dallas, OR 97338

Date: 12/16/2020
Report number: 00117107-AP-090605
Type: Licensing Violation
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)(a)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(G)
External site: 411-054-0036(2)(g)
Findings: Alleged Victim (AV) relies on the facility for his/her care. Documentation and interviews provided to the department indicate AV is care planed for brief changes every two (2) hours as per Cascade Living policy, and TSP dated on or about December 16, 2020, indicates AV is to be repositioned every two (2) hours to relieve pressure on buttocks, rotating to right/left sides. On or about December 16 & 17 2020, Alleged Perpetrator #2 (AP2) was the only person working the Noc shift in the COVID unit from 6:00pm to 6:00am. AV still had on the marked day shift briefs at the end of AP2's 12-hour shift both mornings, AV also had not been repositioned, resulting in unreasonable discomfort to AV. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.