Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00331582-AP-282864
Provider Information
Newberry Estates Memory Care Community
1025 NE PURCELL BLVD
Bend, OR 97701
- Provider ID
- 5MA221
- Administrator
- Britney Werkman
- Phone
- (541) 312-4300
- ed@newberryestatesmc.com
Violation Details
- Date
- 5/11/2024
- Report number
- 00331582-AP-282864
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Rule(s) Violated
-
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
- Findings
- On or about May 7, 2024, the Alleged Victim (AV) moved from the assisted living to the memory care side of the facility. On or about May 11, 2024 AV was found sitting on a bench complaining of pain in his/her knee and on May 12, 2024, AV was unable to bear weight on his/her left leg and was sent out to the hospital and diagnosed with a fractured hip. During AV's transfer from assisted living to memory care, AV's medication for cognition enhancement was not transferred, and the missing medication was not discovered until May 16, 2024, upon AV's return from the hospital. Once AV returned from the hospital, AV experienced recurring falls, mostly from trying to transfer from his/her wheelchair to the bed. On or about May 20, 2024, AV began taking his/her cognition medication again, AV's cognition has drastically improved, resulting in a decrease of falls. The facility's failure to provide a safe medication administration system resulted in AV suffering a fall which resulted in a fractured hip. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00802 $500.00 fine assessed