Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00413708-AP-364901
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
- 7/14/2025
- Report number
- 00413708-AP-364901
- 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)
411-054-0030(1)(e)(H) and (I)
411-054-0036(2)(g)
411-054-0040(2)
- Findings
- On or about July 14, 2025, the Alleged Victim (AV) suffered an unwitnessed fall in the facility's North courtyard. At time of incident, AV was found lying on the ground between 3:00PM and 3:20PM and outside temperatures were between 85 and 93 degrees. Based on facility documentation and interviews, AV's placement in memory care is due to AV's significant cognitive deficits and mobility issues which require constant supervision and support. These deficits make AV vulnerable to extreme heat due AV not being able to understand the risks associated with his/her surroundings. AV was last seen in his/her room between 2:20PM and 2:30PM. Although the times provided by witnesses regarding the last time AV was physically seen are approximated, an investigation determined the likely amount of time that AV was on the ground range from 30 minutes to almost an hour. The timeline may be within AV's 1-hour safety check protocol; however, AV was outside long enough to have been negatively affected by the heat. AV complained of pain and heat related discomfort and was taken to the hospital and treated for Heat Illness. The combination of heat and inadequate supervision by facility staff, significantly increased AV's risk of heat-related illness. The facility failed to provide the basic care or services necessary to maintain the health and safety of AV, resulting in AV suffering from Heat Illness, placing AV at risk of serious harm due to AV's fall history requiring frequent safety checks. The facility's failure is a serious violation of resident rights, is considered neglect of care which constitutes abuse. Additional corrective action was taken concerning this case. ODHS issued condition, RCFCD25-00776, effective July 17, 2025.
- Sanction
- RCFCP25-00970 $2500.00 fine assessed