Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00311799-AP-280506
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
- 11/22/2023
- Report number
- 00311799-AP-280506
- 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)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(H) and (I)
External site: 411-054-0036(2)(b), and (g)
- Findings
- Alleged Victim (AV) Service Plan indicates AV is independent in transferring and ambulation and uses a walker to ambulate. AV has a history of falls. Hospital record on or about November 18, 2023, indicates AV had a fall two days ago and was having back pain. AV had two falls on or about November 22, 2023, at approximately 6:50 am and 6:00 pm. At approximately 6:00pm, AV was standing and talking to other residents when s/he went to step around h/h walker and fell backwards, hitting h/h head on the piano. EMS was called to assess AV and transported to the hospital, requiring staples to h/h scalp. Staff observed that AV had become more unsteady approximately one week before s/he began falling on or around November 18, 2023, but the facility did not put any interventions in place to address AV’s decline in mobility. After the first fall on November 22, 2023, interventions put into place to address AV’s risk of falls include if staff see AV wandering around for long periods of time they are to offer for h/h to sit down in a chair in a common area. The intervention put into place after the first fall on November 22, 2023, was not an appropriate intervention. AV was found on the floor at 6:50am and AV had last been seen in bed. There is no evidence that the first fall on November 22, 2023, was due to AV walking for extended periods of time. Interventions able to be recalled by witnesses to reduce AV’s risk of falls include frequent checks. The incident reports for AV’s falls state, “Staff and family are aware that AV can be unbalanced” . There is no service planning around AV’s balance issues and no directions are given to staff on how to assess AV for balance issues or what to do if AV is seen to be having balance issues. The facility failed to appropriately care plan and implement reasonable person-centered interventions to address AV’s unbalance and to mitigate the risk of further falls, which resulted in a second fall on November 22, 2023, at approximately 6:00 pm resulting in AV being transferred to the hospital and receiving staples in h/h head, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01281 $500.00 fine assessed