REDMOND — A 92-year-old woman diagnosed with dementia fell at least 15 times at an assisted living facility in Redmond before she was hospitalized and later died from her injuries, according to a wrongful death lawsuit that alleges staff were negligent.

Georgia Joan Page of Bend fell for the final time about 9:40 a.m. on Jan. 19, 2022, according to the lawsuit filed in the Deschutes County Circuit Court. Staff at Juniper Springs Senior Living didn’t immediately call an ambulance, but instead called the woman’s daughter, Genie L. Kelley, to take her to a hospital, the lawsuit states.

When Kelley helped her mother toward the car, about five hours after Page had fallen, she lost consciousness for the second time that day, the lawsuit states. At that point, a call was made to 911 at roughly 3:15 p.m.

Page, a great-grandmother who enjoyed golf, cards, teaching line dancing and attending her family’s activities, was taken by ambulance to St. Charles Redmond. She was in the hospital for 18 days before she died on Feb. 6, 2022.

According to the death certificate, Page’s immediate cause of death was “immobility associated with rib, sternal and cervical spine fractures” due to “multiple falls from standing height” and slower than normal heart rate and blood pressure.

Her death was listed as an accident.

Juniper Springs opened in 2018, but has been cited by the state several times. Since 2019, state regulators reported seven violations at Juniper Springs, which has 91 licensed beds, according to public reports on the Oregon Department of Human Services website. Violations include failing to protect a resident from physical abuse and failing to protect people who had hundreds of dollars stolen from their rooms, wallets or credit cards. In addition, the state cited Juniper Springs nine times for problems that included failing to report suspected abuse and failing to assess a resident who lost about 13 pounds — about 10% of his/her body weight — in a month. It is not unusual for state regulators to find violations or deficiencies in assisted living facilities.

After the inspections, the state reported Juniper Springs said it would make correction plans, from ensuring assessments will be conducted to providing internal training, state records show.

One of the violations appears to involve Page, records show. Though the state doesn’t name Page, the resident mentioned in the state’s report was hospitalized on the same day with the same injuries, including fractured ribs and vertebrae.

A report said staff failed to adequately care for the resident after experiencing pain and discomfort from a fall on Jan. 19, 2022. The state substantiated the claim of neglect in that case and fined the facility $1,500.

“The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse,” the state concluded.

Updated care plan

Page’s daughter, Kelley, filed the lawsuit on June 15 against Juniper Springs and its two associated companies, PC Redmond LLC, and Compass Senior Living LLC. The lawsuit seeks more than $3.8 million in damages.

Kelley declined to comment. Brian C. Dretke, a Salem-based attorney who represents Kelley, said he had nothing further to add .

Tanya Basl, Juniper Springs’ administrator, did not return a phone call seeking comment. Nicole Scott, the regional director of operations for Compass Senior Living, which oversees Juniper Springs, said in an email to The Bulletin Tuesday: “We still haven’t seen the lawsuit, so aren’t in a position to comment on it.”

In response to questions about the facility’s record, Scott said Juniper Springs is “continually focused on resident care and health to provide a great environment for our residents and families.”

Scott added: “In terms of regulatory experience, Oregon is a self-reporting state and we pride ourselves on the level of transparency we maintain with our regulatory agencies, which results in improvements in processes and contributes to the strong overall quality of resident care at Juniper Springs.”

Staff knew Page was “generally healthy” when she moved into the facility on May 13, 2020, according to court records. She had recently been diagnosed with dementia, “but could make her needs known,” the lawsuit states. She could walk without assistance and did not have a history of falling.

In the following nine months, Page lived “relatively independently,” according to court records. As her needs grew, staff provided additional assistance, dressing her in clean clothes, locating hearing aids, monitoring blood pressure and ensuring she didn’t miss meals.

But the care was inconsistent, the lawsuit states. Kelley grew concerned about a shortage of staff and urged the facility to properly care for her mother, according to court records.

Page fell for the first time on March 2, 2021, according to court records. During the next 10 months, she fell 15 times, the lawsuit states.

At least eight involved injuries, but three falls were only referenced in an assessment with no documentation of the cause or circumstances other than that they occurred in April 2021, according to court records. At the end of April, Juniper Springs staff “updated Georgia Page’s care plan to reflect that she was a high fall risk,” according to court records.

Some of the injuries suffered when she fell were minor — a skinned elbow, a scraped knee, a tender forehead, wounds that staff bandaged before taking her back to bed, according to court records.

Others were more serious, according to the lawsuit. In one incident on April 22, 2021, she fractured her cervical spine and was placed in a cervical collar.

In another on July 20, 2021 she hit her head, bled all over her kitchen sink and bathroom and was hospitalized. In another on Sept. 2, 2021, she fell and was diagnosed with a sternum fracture at the hospital.

After the final fall on Jan. 19, 2022, staff helped her up and noticed that she was limping and complaining of neck pain, according to the lawsuit. They helped her into a recliner and gave her medication and an ice pack. When they helped her to the bathroom, she briefly passed out. Staff called Page’s daughter, Kelley, to take her to the hospital, the lawsuit states.