Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00306625-AP-259488
Provider Information
Churchill Estates Assisted Living
1919 BAILEY HILL RD
Eugene, OR 97405
- Provider ID
- 70M014
- Administrator
- Deborah Hankins
- Phone
- (541) 485-8320
- d.hankins@churchillretirement.com
Violation Details
- Date
- 1/11/2024
- Report number
- 00306625-AP-259488
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
- Findings
- On January 11, 2024, Alleged Victim (AV) had an unwitnessed fall. Based on facility documentation and interviews, it was determined that at time of incident, AV's Temporary Service Plan (TSP) was not being followed. Per Incident Report dated January 9, 2024, AV suffered a fall on January 9, 2024, in which AV's TSP stated AV's door was to remain open to prevent AV from falling. AV's door was closed at the time of January 11, 2024, fall which is contrary to AV's TSP put in place after his/her January 9, 2024, fall. AV has a history of falls with and without injury prior to the January 9, 2024, fall. AV suffered two falls with serious injuries on October 9, 2023, and December 12, 2023, with serious injuries that were previously investigated. The facility failed to implement appropriate interventions related to preventing falls when AV is ambulating, and the facility also failed to provide appropriate supervision related to AV's known history of falls. The facility's failure resulted in AV experiencing several unwitnessed falls, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP24-00177 $338.00 fine assessed