Print Violation: 00279303-AP-233902

Provider Information

Cedarbrook Lodge Senior Living

775 NE 27TH ST
Mcminnville, OR 97128

Date: 8/8/2023
Report number: 00279303-AP-233902
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious 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)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: According to the documentation, the facility failed to ensure the care plan was being followed by escorting the Alleged Victim (AV) on or about August 08, 2023, AV was walking unescorted to the dining room leaning heavily to one side. AV fell and hit their head on the floor sustaining a fracture to their T1 vertebrae. The AV was care planned to be escorted to and from their room as part of fall interventions. The failure resulted in the AV sustaining a fall and fracturing a vertebrae in their back, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP25-00431 $1125.00 fine assessed