Print Violation: 00297561-AP-251118

Provider Information

Awbrey Place Memory Care

2825 NEFF RD
Bend, OR 97701

Date: 11/14/2023
Report number: 00297561-AP-251118
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)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(A) and (H)
Findings: The Alleged Victim (AV) is a known fall risk and has had multiple falls with and without injury. AV is care planned to have a caregiver provide standby assistance while ambulating, however, AV will ambulate without assistance, requiring immediate intervention by staff. AV suffered three falls, November 14, 2023, November 25, 2023 and November 26, 2023, two of those falls causing injury. The facility's failure to ensure oversight of AV while ambulating placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP24-00604 $188.00 fine assessed