Print Violation: 00250233-AP-205994

Provider Information

Bonaventure of Keizer Memory Care

5525 MCLEOD LANE NE
Keizer, OR 97303

Date: 2/12/2023
Report number: 00250233-AP-205994
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(f) and (r)
411-054-0028(2)
Findings: Alleged Victim (AV) relies on the facility for all of his/her care needs. On or about February 23, 2023, AV was transferred from the hospital to the facility with a stage 3 pressure ulcer to his/her sacrum. On that same day, the facility received medical records, including a copy of AV’s hospital after visit summaries. AV's after visit summary contained a referral and instruction to follow up with Amedisys Home Health for RN wound assessment, and specific wound care instructions for AV’s stage 3 pressure injury. Between February 23rd, through March 2nd, 2023, the facility failed to coordinate Home Health wound care services and the facility failed to provide wound care to AV. As a result, AV was transported to the hospital on March 3, 2023, where it was discovered that AV was diagnosed with a MRSA infection to his/her pressure ulcer. The facility failed to provide service around AV’s known would and would care, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP24-00097 $500.00 fine assessed