Print Violation: 00317030-AP-269098

Provider Information

Avamere Court at Keizer RCF

5210 RIVER ROAD N
Keizer, OR 97303

Date: 3/5/2024
Report number: 00317030-AP-269098
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)(g)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered by failing to have an accurate medication management system in place to correctly administer AV's medication and train staff. Based on facility documentation and interviews, AV did not get his/her diuretic prescription for several days. The medication error resulted in AV suffering shortness of breath, weight gain, edema in legs and abdomen, neck vein distention, and difficulty walking. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.
Sanction: RCFCP24-00855 $1500.00 fine assessed