Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: CALMS - 00085635
Provider Information
Newberry Estates Memory Care Community
1025 NE PURCELL BLVD
Bend, OR 97701
- Provider ID
- 5MA221
- Administrator
- Britney Werkman
- Phone
- (541) 312-4300
- ed@newberryestatesmc.com
Violation Details
- Date
- 7/14/2025
- Report number
- CALMS - 00085635
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Rule(s) Violated
-
411-054-0025(4)
- Findings
- Based on interview and record review, conducted during a site visit on 07/21/25, the facility’s failure to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare or residents was substantiated for 1 of 1 sampled resident (#1). This posed an immediate harm situation, which put the health and safety of residents at risk. Findings include but are not limited to: A review of facility meeting notes dated 07/17/25 with participants listed regarding the incident on 07/14/25 including an attachment undated showing the facility policy to be locking the courtyard doors when outside temperatures reached 95 degrees. A review of the ER After Visit Summary dated 07/14/25 indicated the following: - Resident temperature 97.9 F - Reason for visit: Fall - Diagnosis: Heat collapse A review of the policy for securing courtyard doors as of 07/17/25 following condition being placed on the building indicated the following: - Excessive heat (temperatures above 85 degrees) - Heavy rain - Excessive winds - Poor air quality - Excessive freezing temperatures - Hail, Ice, Snow - Weather advisories - National Weather Service - Police issued shelter in place A review of the Safety plan for the courtyards as of 07/17/25 following condition being placed on the building indicated the following: - Sign off sheets for courtyard checks - Documentation hourly for courtyard doors locked - Assigned caregivers at specific courtyards - Documentation of all resident safety checks A review of Resident 1’s progress notes dated 07/01/25 through 07/21/25 indicated the following: - Residents initial fall outside 07/14/25; - Residents return from hospital post fall with heat illness dated 07/14/25; - Safety checks placed 07/15/25; - Push hydrating fluids as tolerated; - On 07/16/25, the resident had another fall and sent to hospital; - On 07/18/25 the resident had chest pain was sent out to the hospital; and - On 07/19/25 the resident had another fall and was sent to hospital. During an interview with Staff 1 stated they were no longer documenting safety checks after June 9th, 2025, when the previous condition had been lifted. Staff 1 confirmed the facility had made adequate efforts to support and remedy the violations that were placed by The State on 07/17/25 and stated that the courtyard door policy was currently under review by the president and vice president of the company. The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents during extreme heat. This resulted in the resident being hospitalized. The findings of the investigation were reviewed and acknowledged by Staff 1. The facility’s failure to exercise reasonable precautions is a violation of Oregon Administrative Rules.