Print Violation: 00346491-AP-296897

Provider Information

Tsl Elderhealth And Living Memory Village

382-B SOUTH 58TH ST
Springfield, OR 97478

Date: 8/2/2024
Report number: 00346491-AP-296897
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
Findings: The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her care needs. On or about August 2, 2024, AV was found outside of the facility after the exit gate was left open by a new staff member. Based on facility documentation, the new staff member did not receive specific training on closing the exit gate. The gate procedure was not included in the new hire training handbook, and there was no documented evidence of consistent gate training being provided to new staff. Despite AV's known exit-seeking behaviors, AV's care plan did not provide appropriate interventions to mitigate AV's known risk behavior. AV has a documented history of exit-seeking behaviors dating from March 2024 through August 2024. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP24-01091 $188.00 fine assessed