Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00412604-AP-363792
Provider Information
Bayberry Commons Memory Care
2211 LAURA STREET
Springfield, OR 97477
- Provider ID
- 50R347
- Administrator
- Amanda Bristow
- Phone
- (541) 744-7000
- ed@bayberrysl.com
Violation Details
- Date
- 7/7/2025
- Report number
- 00412604-AP-363792
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(a), (g) and (s)
External site: 411-054-0028(2)(a) and (b)
External site: 411-054-0030(1)(e)(f)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a), and (f)
- Findings
- Alleged Victim (AV) has diagnosis of progressive cognitive impairment, memory loss, hypertension, atrial fibrillation, and congestive heart failure. AV is a resident of a locked memory care facility, which is responsible for providing care, including ordering, storing, and administering all medications to AV. Staff are to begin working on refills of a medication when a resident has seven days left of the medication. AP1 procedures instruct staff to place a resident on alert charting at the first dose of missed medication and to continue documenting attempts to obtain the medication. AP1 uses a computer system which emails a daily report of missed medications. AP1 management staff failed to review the missed medication report. AV is prescribed blood thinning medication twice a day. On or about June 22 and 23, 2025, AV missed the 8:00am dose of AV's blood thinning medication, and all doses from June 26, 2025, to July 7, 2025. AV missed the 8:00am of beta blocker medication from June 27, 2025, to July 2, 2025. During the period of June 22, 2025, to July 7, 2025, AV was not placed on alert charting for the missed blood thinning medication. AV was on alert charting for other missed medications. On or about July 7, 2025, AV began to show stroke-like symptoms and was sent to the hospital. While at the hospital, AV's blood was found to be out of intended therapeutic range of someone on blood thinning medication. AV returned to AP1 after being hospitalized but with significant deficits, including never regaining consciousness. AV passed away on July 12, 2025. The facility failed to provide a safe medication administration system and administer medication as ordered, which is a violation of resident rights is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00931 $2500.00 fine assessed