Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00351840-AP-302169
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
- 8/30/2024
- Report number
- 00351840-AP-302169
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Rule(s) Violated
-
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(H) and (I)
411-054-0036(2)(g)
411-054-0037(1)
411-054-0040(2)
411-054-0070(1)(d)(e)(f)(i)
- Findings
- On or about August 30, 2024, at approximately 11:50am, Alleged Victim (AV) was found unresponsive by facility staff in the outdoor courtyard of the facility. EMS was contacted and AV was transported to the hospital for treatment. Based on facility documentation and interviews, AV was dressed in warm clothing, including two sweaters, one described as a heavy winter fleece, and long pants. Per the U.S. Government's National Oceanic and Atmospheric Administration, the temperature the day of the incident rose from 72 degrees Fahrenheit at 8:55AM to 90 degrees Fahrenheit at 11:55AM, five minutes after AV was reportedly discovered. EMS reported that AV's temperature was 109 degrees Fahrenheit and AV's temperature upon arrival at the hospital was documented as 103.6 degrees Fahrenheit after ice packs had been used to decrease AV's body temperature. AV required resuscitation and intubation to protect AV's airways while in the Emergency Department. AV was admitted to the hospital's Intensive Care Unit, where AV ultimately passed away on September 1, 2024. The county Medical Examiner determined AV's cause of death was multi-system organ failure due to hyperthermia with contributing factors of AV having dementia and being left outside in extreme heat. At time of incident, facility records show only one care staff was working the day shift on August 30, 2024. The facility's posted staffing plan indicated there are to be 3 caregivers and 2 med techs working dayshift. The staff schedule for the day only had 2 caregivers and 1 med tech which did not meet the posted staffing. The two scheduled caregivers for the day called out sick and no additional facility staff or agency staff were called in. At time of incident, there was a total of 33 residents present at the facility during the dayshift on August 30, 2024. Facility did not have a written policy in place regarding safety checks of residents in the courtyard areas of the facility. Additionally, there was significant inconsistencies in witnesses report of the facility's practice of safety checks of the courtyards, or even the existence of a policy, suggesting that the expectations were clear to staff. The facility failed to provide adequate staffing to ensure the safety and supervision of the resident which resulted in AV sitting outside for an unknown amount of time in clothing inappropriate for the weather conditions at time of incident. The facility's failure The facility's failure to provide a safe environment, have effective oversight of residents, and ensure there were enough properly trained staff available to have oversight of all residents resulted in AV suffering a heat stroke/hyperthermia that resulted in AV's death which is a serious violation of resident rights, is considered serious neglect of care, which constitutes abuse. ODHS found this incident to be a risk of Immediate Jeopardy at time of initial intake, in which ODHS issued Immediate Jeopardy Condition, RCFCD24-00925, on September 13, 2024, prior to completion of APS Investigation, #0035180, because the facility’s failure to comply with Oregon Administrative Rules likely resulted in death of AV which was confirmed on July 1, 2025, at time APS Investigation, #0035180 was completed.
- Sanction
- RCFCP25-00754 $15000.00 fine assessed