Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00466672-AP-419340
Provider Information
Lakeland Senior Living
261 LOTO STREET
Eagle Point, OR 97524
- Provider ID
- 70M234
- Administrator
- Veronica Ward
- Phone
- (541) 423-2333
- hsm@lakelandsl.com
Violation Details
- Date
- 3/29/2026
- Report number
- 00466672-AP-419340
- Type
- Abuse: Neglect
- 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)
411-054-0027(1)(g) and (s)
411-054-0028(2)(a) and (b)
411-054-0036(2)(g)
- Findings
- The Alleged Victim (AV) resides in the Respondent’s facility and relies on facility staff to ensure that AV’s basic care, safety, and supervision needs are met. AV has a documented history of falls, including an incident on March 1, 2026, when AV attempted to get out of bed and slipped, and another incident on March 21, 2026, when AV fell in the bathroom during the night and remained on the floor for several hours because AV did not have AV’s call pendant. AV’s service plan indicates that AV can appropriately use the call pendant, uses a cane or four-wheel walker for ambulation, and that nighttime staff will retrieve the urinal from the bathroom and place it within AV’s reach for nighttime use. After the fall on March 1, 2026, interventions included staff monitoring AV more closely and reminding AV that staff are available to assist as needed. Following the fall on March 21, 2026, AV was added to NOC shift rounds twice nightly. Despite these interventions, the facility failed to provide a safe environment and did not follow AV’s service plan or the interventions intended to mitigate AV’s fall risk. On or about March 28, 2026, AV was last seen at approximately 9:00 p.m. during medication pass. AV slipped, lost balance, and struck AV’s head on the floor while ambulating to the bathroom. AV remained on the floor for approximately six hours until activating the bathroom pull cord at around 3:00 a.m. on March 29, 2026. The Respondent failed to provide a safe environment and did not follow AV’s service plan or interventions. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(A)(i).
- Sanction
- ALFCP26-00281 $500.00 fine assessed