Print Violation: 00424646-AP-376195

Provider Information

The Arbor at Avamere Court

450 CLAGGETT COURT N
Keizer, OR 97303

Date: 9/5/2025
Report number: 00424646-AP-376195
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: On September 5, 2025, ODHS Adult Protective Services (APS) initiated investigation #00424646 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. On September 4, 2025, the Alleged Victim (AV), who has a documented history of falls, experienced an unwitnessed fall while seated in his/her recliner. AV's fall resulted in physical injuries including a hematoma on the forehead, and skin tears to the left elbow and left knee. AV’s care plan included specific fall prevention interventions, notably the placement of a chair sensor in AV’s recliner to alert staff when AV attempted to stand or move. The facility failed to ensure that this intervention was properly implemented. The absence or malfunction of the chair sensor contributed to the lack of timely supervision and response, resulting in AV’s fall and subsequent injuries. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP25-01460 $1000.00 fine assessed