Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00354768-AP-305107
Provider Information
Brookdale Salem
1355 BOONE RD SE
Salem, OR 97302
- Provider ID
- 5MA205
- Administrator
- April Reinhart
- Phone
- (503) 365-7500
- april.reinhart@brookdale.com
Violation Details
- Date
- 9/6/2024
- Report number
- 00354768-AP-305107
- 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: 411-054-0036(2)(g)
- Findings
- According to the documentation, the facility failed to properly care plan for the Alleged Victim’s (AV) known fall history and risk of injury. The AV was previously independent with ambulation but recently was identified as needing ambulation assistance due to numerous falls. From approximately July 14, 2024, through September 06, 2024, the AV experienced approximately four (4) falls. There were no documented interventions which would prevent the AV from continued falls. On or about September 06, 2024, the AV experienced an unwitnessed fall in the facility’s town hall room. The AV notified staff of pain on their right side and had trouble moving their leg. Hospice RN assessment determined the AV did not have a fracture. The next day on or about September 07, 2024, the AV experienced a significant change of condition and overall decline in ability to ambulate. The AV needed 2x transfer assistance and expressed extreme pain in their right leg and could not bear any weight on their leg. On or about September 14, 2024, the AV received an X-ray showing there was a fracture in the AV’s Trochanter. The AV experienced extreme pain and a fracture due to the facility not properly care planning appropriate interventions for the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00139 $1125.00 fine assessed