Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00179170-AP-142413
Provider Information
Reflections Memory Care
2480 CORAL AVE NE
Salem, OR 97305
- Provider ID
- 50R298
- Administrator
- Nadia Lopez-Morales
- Phone
- (503) 362-5885
- nadia@sweetbyenbye.com
Violation Details
- Date
- 11/27/2021
- Report number
- 00179170-AP-142413
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- 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: 411-054-0030(1)(e)(A)(H) and (I)
External site: 411-054-0036(2)(b), (c) and (g) 411-054-0045(2)(a)(A) and (B)
- Findings
- Alleged Victim's (AV's) Home Health Physical Therapy note dated August 23, 2021, indicates AV has a cognitive deficit, and has a strong tendency to lean back when sitting unsupported, standing, and walking, making AV a high risk for falls. Temporary Service Plan (TSP) dated on or about October 5, 2021, recommend, walk with AV to dining room using walker with 1-person contact guard assist. On or about October 23, 2021, it is noted that AV has a history of impulsive behavior and falling. Service plan dated on or about November 13, 2021, indicates AV requires 1-person hands-on assist to shower; 1-person assist with transfers using gait belt; can use a walker and ambulates with 1-person assist; can self-propel with a wheelchair; needs 1-person assist to toileting; staff to toilet AV at least 6 times per shift and as needed, and is a high fall risk. AV will wear tab/pad alarm at all times, staff to ensure it is turned on; will use a scoop mattress in hospital bed; staff to check AV 6 times per shift to ensure all needs are met; AV will wear velcro posey belt at all times when sitting in h/h recliner; and is a full assist with night needs. Staff to do a visual check on AV 6 times per shift or as needed to change h/h Depends and ensure needs are met. On or about November 27, 2021, staff in AV's room helping AV back to bed when AV leaned back hitting the wall and slid to the ground resulting in an abrasion to h/h right elbow. The physical therapy notes indicate AV has strong tendency to lean back when sitting unsupported, the TSP with PT instructions and AV service plan makes no mention of AV’s strong tendency to lean back and does not provide guidance on how to prevent falls related to this tendency. The facility failed to appropriately care plan and implement person centered interventions to address AV’ tendency to lean back, resulting in AV falling and sustaining an abrasion, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00262 $250.00 fine assessed