Print Violation: 00444484-AP-396475

Provider Information

Newberry Estates Memory Care Community

1025 NE PURCELL BLVD
Bend, OR 97701

Date: 12/10/2025
Report number: 00444484-AP-396475
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
Findings: On or about December 10, 2025, Alleged Perpetrator 2 (AP2) threatened Alleged Victim (AV) with a “time out” and pushed AV’s wheelchair against a wall so forcefully that AV’s knees were touching the wall. When AV attempted to stand, AP2 restrained AV by pressing down on AV’s shoulders, preventing AV from standing. AV is a resident in memory care with a diagnosis of a memory-related disease and requires staff assistance for behavior management, orientation, and redirection. Facility documentation and interviews confirm AP2 had completed required trainings on dementia care, wandering/elopement, and resident rights. At the time of the incident, AP2 was described as short-tempered and was observed applying physical restraint to AV. AP2's actions constitute wrongful restraint, which is considered abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.