Print Violation: 00434112-AP-385985

Provider Information

The Arbor at Avamere Court

450 CLAGGETT COURT N
Keizer, OR 97303

Date: 10/20/2025
Report number: 00434112-AP-385985
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
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)
External site: 411-054-0040(b) and (c)
Findings: On January 27, 2026, ODHS Adult Protective Services (APS) completed investigation #00434112 and issued a written investigation report, which is incorporated here by reference. The Alleged Victim (AV) resided at the Respondent’s facility. The facility failed to implement and consistently follow progressive, appropriate, and effective fall-prevention interventions to mitigate AV’s known fall risk. On or about October 20, 2025, AV sustained abrasions to both knees after falling in the bathroom. Based on facility documentation and interviews, AV had a significant fall history prior to incident, experiencing more than 20 falls since May 2025, several of which resulted in injuries. These repeated failures to provide adequate supervision and interventions caused multiple unwitnessed falls, unreasonable discomfort, which is a violation of resident rights., is considered neglect of care and constitutes abuse.
Sanction: RCFCP26-00156 $1125.00 fine assessed