Print Violation: 00133690-AP-104805

Provider Information

Bonaventure of Salem Assisted Living

3411 BOONE RD SE
Salem, OR 97317

Date: 2/14/2021
Report number: 00133690-AP-104805
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: Alleged Victim’s (AV’s) care plan dated July 29, 2020, indicated that AV is not a fall risk, no fall prevention interventions are noted in the service plan. Between November 2020 through February 18, 2021, AV sustained six (6) falls. As a result, AV sustained injuries on four (4) of those falls, and he/she was sent to the emergency room twice. After AV had fallen on a fifth (5th) occasion, it was noted in the Progress Notes that AV had become a 2-person transfer. No update to the Service Plan was noted, there were no change of condition assessments or other fall interventions noted to further prevent AV from sustaining falls. The facility failed to properly care plan around AV’s falls, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: ALFCP24-00071 $500.00 fine assessed