Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00300152-AP-253555
Provider Information
Avamere Court at Keizer RCF
5210 RIVER ROAD N
Keizer, OR 97303
- Provider ID
- 50R068
- Administrator
- Michelle Boger
- Phone
- (503) 393-3624
- mboger@avamere.com
Violation Details
- Date
- 10/16/2023
- Report number
- 00300152-AP-253555
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (b)
- Findings
- The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, between October 16, 2023, and November 27, 2023, the facility failed to administer eleven different medications to Alleged Victim (AV) on approximately forty-five separate days, resulting in seventy missed administrations of AV's prescribed medications. AV's missed medications were prescribed to treat gastrointestinal discomfort, nausea, constipation, shortness of breath, moderate to severe pain, and anxiety. Four more of AV's missed medications were prescribed to treat AV's chronic mental health disorders. As a result, AV suffered unnecessary anxiety, shortness of breath, paranoia, and nausea. Based on facility documentation and interviews, the facility failed to provide adequate training and orientation to Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3). AP2 and AP3 were inexperienced in the type of facility they were charged with managing. The facility's failure to provide a safe medication system caused AV pain and discomfort that lasted more than 24 hours, is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) allegedly neglected AV. An investigation determined no abuse occurred by AP2 and AP3.
- Sanction
- RCFCP24-01259 $2500.00 fine assessed