Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00179170-AP-326316
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-326316
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- 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), and (G-I)
External site: 411-054-0036(2)(b), (c) and (g)
- 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. Staff entered AV's room, observed AV getting out of bed unassisted and falling. Interventions put into place, to continue frequent checks to ensure safety. 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, AV leaned back hitting the wall and slid to the ground resulting in an abrasion to h/h right elbow. On or about December 16, 2021, staff assisting AV to toilet, left AV alone in the bathroom in order to step out and grab a brief from the bed. While AV was left unattended, AV stood up and fell, sustaining bruises on left shoulder, upper back, right thigh and hip. AV's 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 service plan indicates 1-person assist with transfers using gait belt; needs 1-person assist to toileting; AV is a high fall risk; Staff to ensure needs are met. The facility failed to provide a safe environment and failed to follow AV's care plan resulting in AV falling and sustaining multiple abrasions, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00262 $250.00 fine assessed