Print Violation: 00326661-AP-278097

Provider Information

Bonaventure of Keizer Memory Care

5525 MCLEOD LANE NE
Keizer, OR 97303

Date: 4/12/2024
Report number: 00326661-AP-278097
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious 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) is care planned to be a known fall risk. AV’s service plan required staff to ensure AV used his/her walker at all times and if staff saw AV without his/her walker, staff were to get it for AV. On or about April 12, 2024, AV fell int the facility and as a result, he/she sustained a hip fracture which required surgery. At the time of the fall, AV’s walker was not within AV’s reach. Staff who had an opportunity to bring AV’s walker to AV just before the fall, had not reviewed AV’s service plan in six (6) months. The facility failed to assure AV’s service plan was being followed, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP24-01147 $1125.00 fine assessed