Print Violation: 00054065-AP-037815

Provider Information

Bonaventure of Keizer Assisted Living

5525 MCLEOD LANE NE
Keizer, OR 97303

Date: 10/17/2019
Report number: 00054065-AP-037815
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(I)
External site: 411-054-0036(2)(g)
Findings: The facility failed to implement effective interventions and appropriately monitor the Alleged Victim (AV) according to his/her known needs related to falls and catheter care. On or about October 17, 2019, AV experienced an unwitnessed fall where s/he was found approximately 3.5 hours later with his/her catheter completely removed, causing unreasonable discomfort and a loss of personal dignity. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP20-00587 $500.00 fine assessed