Print Violation: 00324664-AP-276263

Provider Information

Cedarbrook Place Senior Living

721 NE 27TH ST
Mcminnville, OR 97128

Date: 3/16/2024
Report number: 00324664-AP-276263
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 follow the care plan for the Alleged Victim (AV) to keep their floor free of trip hazards due to continued falls. From approximately February 13, 2024, through March 16, 2024, the AV fell approximately three times. After the second fall, a temporary service plan was created to encourage a trip hazard free floor. Approximately 11 days later, the AV suffered another fall by tripping on a mat in their room. The fall on or about March 16, 2024, resulted in the AV fracturing their hip and refusing surgery, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP25-00469 $1125.00 fine assessed