Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00307731-AP-260565
Provider Information
Willamette Springs Memory Care
6000 SW MOSAIC DRIVE
Corvallis, OR 97333
- Provider ID
- 50M436
- Administrator
- Kimberly Blanchard
- Phone
- (541) 497-9707
- ed@willamettesprings.com
Violation Details
- Date
- 11/1/2023
- Report number
- 00307731-AP-260565
- 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: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
- Findings
- On October 17, 2023, Alleged Victim (AV) was admitted to hospice. Between October 17, 2023, and October 28, 2023, AV is regularly documented to be short of breath; hospice instructions left on October 28, 2023, state that AV should receive "frequent supervision, every two hours" to monitor AV for shortness of breath, with instructions that AV should receive narcotic medication if found to be short of breath. AV received h/h scheduled medications on October 31, 2023, at 2000 hours. AV received a breakfast meal tray delivered to h/h room on November 1, 2023. Alleged Perpetrator 3 (AP3), who was assigned to AV's section during day shift of November 1, 2023, looked in AV's room at the beginning of h/h shift and AV appeared asleep in h/h chair; AP3 did not have any additional contact with or observation of AV until after AV was found deceased. AV was in the same position when found deceased as AP3 had observed AV at the beginning of the shift. Alleged Perpetrator 2 (AP2), who was responsible for AV's section on NOC shift from October 31, 2023, to November 1, 2023, could not be identified. AV can last be confirmed alive on October 31, 2023, at approximately 2000 hours, when AV received h/h scheduled medications from Witness 2 (W2). AV's time of death could not be determined, it is unclear on which shift AV died, leaving the allegations against both AP2 and AP3 inconclusive. The facility failed to update and properly plan AV’s care with h/h changing needs as AV experienced an expected decline in health and ability after starting hospice services; The facility failed to follow and implement instructions to staff following the orders from hospice staff, provided on October 28, 2023, that AV was to be frequently monitored, defined as every two hours, for AV's known shortness of breath; these failures resulted in AV going an extended period of time without any staff contact or monitoring, during which time AV died.
- Sanction
- RCFCP24-00531 $1500.00 fine assessed