Print Violation: 00427829-AP-379513

Provider Information

Cedar Village Memory Care Community

4452 LANCASTER DR NE
Salem, OR 97301

Date: 9/18/2025
Report number: 00427829-AP-379513
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: 411-054-0036(2)(b) and (g)
Findings: The Alleged Victim (AV) is a known fall risk and has suffered repeated falls. Although AV's service plan diagnosis section notes that AV has repeated falls, AV's service plan did not contain a fall risk section. On or about September 18, 2025, AV was found in his/her room on the floor at 4:30 am. Staff placed AV back into his/her wheelchair and determined no injury to AV from this fall. After this fall, the facility completed a temporary service plan (TSP) with interventions to decrease AV's falls, however, day shift staff had not reviewed AV's TSP that had been produced earlier that morning. At approximately 11:30 am the same day, AV was found in his/her room, asleep in his/her wheelchair with visible injuries to his/her head and right elbow. AV was transferred to the emergency room where he/she was diagnosed with a fractured tailbone, a fractured collar bone and a brain bleed.
Sanction: RCFCP25-01456 $1125.00 fine assessed