Print Violation: 00469417-AP-421949

Provider Information

Azalea Gardens Senior Living

755 ELK DRIVE
Brookings, OR 97415

Date: 1/27/2026
Report number: 00469417-AP-421949
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0025 (1)(a) and (b)
411-054-0027 (1)(g) and (s)
411-054-0028 (2)
411-054-0036 (2)(e)(g)
Findings: The Alleged Victim (AV) is a fall risk and has a history of falls. According to an investigation, on or about January 27, 2026, AV was found on the floor. The AV was sent to the hospital on January 30, 2026, related to severe pain and diagnoses with a lumbar compression fracture. No new fall or safety interventions were developed or implemented to mitigate additional falls or injuries. The AV fell two additional times, on March 25, 2026, and on April 8, 2026. The facility failed to appropriately care plan, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.
Sanction: ALFCP26-00278 $1125.00 fine assessed