Print Violation: 00323578-AP-275511

Provider Information

Bonaventure of Keizer Memory Care

5525 MCLEOD LANE NE
Keizer, OR 97303

Date: 4/1/2024
Report number: 00323578-AP-275511
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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 (AV) was on hospice and had a crushed medication order in place. Alleged Perpetrator 2 (AP2) forced a pill down AV’s throat after a crush was put in place and tried to give AV medication that had been discontinued. AP2 was witnessed not following orders. AP2 failed to follow the care plan around crushed medications for AV, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was being followed, which is a violation of Oregon Administrative Rules.