Print Violation: 00432985-AP-384869

Provider Information

Bonaventure of Salem Memory Care

3411 BOONE RD SE
Salem, OR 97317

Date: 10/12/2025
Report number: 00432985-AP-384869
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
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) relies on the facility for his/her care needs. On or about October 12, 2025, 7:00 AM, AV fell in the hallway, suffering a skin tear to AV's left elbow, and redness to AV's left knee. The only Progress Note created for AV on October 12, 2025, states that AV did not want to bear weight after the fall and was using a wheelchair since AV was not walking after the fall. The only Progress Note created for AV on October 13, 2025, is an RN Change of Condition Note indicating an RN saw AV in a wheelchair in the common area sleeping, assessed the skin tear to AV's elbow, placed AV on a wound log, and noted no redness to AV's knees or symptoms of pain or discomfort. On or about October 14, 2025, AV once again sustained a fall, and as a result, sustained a laceration to his/her lips, right facial orbit swelling and bruising, and reopening AV’s right elbow skin tear. Respondent failed to implement meaningful interventions for falls, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00322 $500.00 fine assessed