Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00416024-AP-367287
Provider Information
Bonaventure of Salem Assisted Living
3411 BOONE RD SE
Salem, OR 97317
- Provider ID
- 70A320
- Administrator
- KELLY BARRICK
- Phone
- (503) 480-0004
- executivedirectorslm@livebsl.com
Violation Details
- Date
- 7/10/2025
- Report number
- 00416024-AP-367287
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide service
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(I)
- Findings
- The facility was responsible for managing Alleged Victim’s (AV’s) medications. AV had major depressive disorder. Staff were to watch for signs of new or worsening depression symptoms including verbalized expressions of sadness, hopelessness, suicidal ideation, self-harm, and other symptoms. On or about May 15, 2025, AV threatened to commit suicide and AV said AV wanted to die. AV said AV wanted to “end it all.” On or about 15, 2025, AV told Witness 2 (W2) and Witness 3 (W3) that AV did not want to continue taking medications that would prolong AV’s life. AV refused medications and took medications inconsistently from May 15, 2025, to July 10, 2025. On or about July 10, 2025, AV had refused all but one of AV’s medications the previous two days. On or about July 10, 2025, AV left the facility and jumped off of an overpass. On or about July 14, 2025, AV subsequently passed away at the hospital from AV’s injuries. AV had a diagnosis of major depressive disorder. AV had active depression and mood problems. AV was under treatment for mental health related issues and was taking medication to manage AV's depression symptoms. Respondent failed by failing to provide the basic care and services of following medication management and failing to notify AV's PCP about medication refusals and suicidal ideation, causing physical harm due to AV becoming suicidal, jumping from an overpass, and dying from h/h injuries, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- ALFCP26-00162 $1500.00 fine assessed