Print Violation: 00180842-AP-330573

Provider Information

Bonaventure of Keizer Memory Care

5525 MCLEOD LANE NE
Keizer, OR 97303

Date: 1/4/2022
Report number: 00180842-AP-330573
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)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: Alleged Victim’s (AV’s) service plan dated September 30, 2021, instructs staff to keep AV active during the day and to provide eight (8) safety checks per shift, and toileting AV four (4) times per shift. Between November 19, 2021, thru December 4, 2021, AV fell four (4) times, once while self-transferring from bed to the wheelchair, once at the floor of his/her bed, once on the floor of the bathroom, and once on the floor in front of the bathroom. There were no new fall prevention interventions noted for AV after these falls were noted, only the safe interventions as noted in AV’s September 30, 2021, service plan. The facility failed to care plan and mitigate AV’s risk of fall, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00342 $500.00 fine assessed