Print Violation: 00414459-AP-365707

Provider Information

Cascades of Bend Retirement Community

1801 NE LOTUS DR
Bend, OR 97701

Date: 7/16/2025
Report number: 00414459-AP-365707
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: 411-054-0030(1)(e)(A)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) has suffered prior falls while ambulating. AV uses a wheelchair for ambulation; however, AV's care plan wasn't updated to advise staff of safety measures while assisting AV in his/her wheelchair. On or about July 16, 2025, staff were pushing AV in his/her wheelchair. AV did not have footrests on his/her wheelchair, resulting in AV putting his/her feet on the ground, causing AV to fall from the wheelchair to the floor, causing AV to have a skin tear to his/her nose. AV was sent to the hospital and diagnosed with a fractured nose, as well as receiving stitches to his/her nose. The respondent's failure to properly care plan, to ensure staff were ensuring AV had footrests on his/her wheelchair for safety. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00072 $1125.00 fine assessed