Print Violation: 00446301-AP-398390

Provider Information

The Arbor at Avamere Court

450 CLAGGETT COURT N
Keizer, OR 97303

Date: 12/21/2025
Report number: 00446301-AP-398390
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)
Findings: The facility failed to implement effective interventions and provide adequate supervision despite the Alleged Victim’s (AV) known high fall risk and documented history of falls. On 12/21/25, AV sustained an unwitnessed fall, resulting in a head injury with a baseball-sized hematoma and multiple abrasions to the upper left eyebrow. Based on facility documentation and interviews, AV had experienced eight falls in 2025 prior to temporarily transferring to this facility on 12/10/25 and was known to place themself on the floor. The facility’s failure to provide appropriate supervision and fall-prevention measures resulted in multiple unwitnessed falls, causing unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP26-00308 $1500.00 fine assessed