Print Violation: 00394267-AP-344941

Provider Information

Newberry Estates Memory Care Community

1025 NE PURCELL BLVD
Bend, OR 97701

Date: 4/8/2025
Report number: 00394267-AP-344941
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: On or about April 8, 2025, Alleged Victim (AV) suffered a fall while left unattended in the common area of the facility. Shortly before incident, two caregivers assisted AV from his/her bed to his/her wheelchair because it was lunchtime, leaving AV unattended in the common area to assist other residents to the dining room for lunch. Based on facility documentation and interviews. The caregivers that assisted AV forgot to place the foot pegs on AV's wheelchair as directed by AV's fall prevention plan. AV is bed bound and only gets up for mealtimes. AV is a two person assist with transfers, is on hospice, is at end of life receiving only comfort measures, and is non-verbal. The facility had caregivers involved in incident repeat their training on how to read a service plan to prevent falls. The investigation determined the facility failed to follow AV's fall prevention plan as stated in AV's care plan and failed to ensure staff were well trained on AV's fall prevention plan, which resulted in risk of serious harm to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP25-00755 $1125.00 fine assessed