Print Violation: 00411919-AP-363053

Provider Information

Brookstone Alzheimer's Special Care Center

5881 WOODSIDE DR SE
Salem, OR 97306

Date: 7/3/2025
Report number: 00411919-AP-363053
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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: The Alleged Victim (AV) relies on the facility for his/her care. AV was care planned to have slippers on during transfers with sit-to-stand and two staff assisting with the transfer. According to an investigation, on or about July 3, 2025, the Alleged Perpetrator 2 (AP2) did not follow AV’s care plan during a sit to stand transfer, resulting in an injury to AV’s right foot and left forearm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the AV's care plan was followed, which is a violation of Oregon Administrative Rules.