Bonaventure of Keizer Memory Care

Alleged Victim’s (AV’s) care plan dated September 11, 2024, states AV is to be toileted every morning between 4-5 AM to prevent AV from needing to get up on his/her own and use the bathroom, AV is not considered a fall risk. On or about September 18, 2024, AV was found on the floor in his/her room by caregiver at around 6:50 AM. AV had a history of falls with three (3) prior falls. Staff reported not understanding the purpose behind the service plan intervention of checking AV between 4 AM and 5 AM. The facility failed to provide service by having staff not understand the care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) service plan dated August 11, 2024, sates he/she has a pattern of falls, but it also states, AV is NOT a fall risk at this time. On or about September 10, 2024, AV was found on the floor by staff after an unwitnessed fall. As a result of the fall, AV was sent to the ER and was found to have sustained a fractured shoulder. The facility failed to service plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of being aggressive toward other residents and staff, causing injury to other residents. On or about July 29, 2024, when Alleged Victim (AV) and W1 were alone in a room together AV was found on the floor, holding AV’s head, looking upset, and a skin tear had reopened on AV’s arm. AV said someone hit AV and W1 was seen walking away agitated and red faced. The facility failed to provide a safe environment for AV, which put AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) service plan dated August 11, 2024, states he/she has a pattern of falls, but it also states, AV is NOT a fall risk at this time. On or about July 14, 2024, AV had a fall in which he/she received a closed head injury, hematoma and stiches. On or about July 15, 2024, while in the dining room, AV had another fall in which he/she received a black eye to his/her right eye. The facility failed to properly plan care and mitigate AV’s risk of falls, which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be at risk of elopement. On or about June 24, 2024, AV had an elopement and went to a 7-11 store and called his/her adult child. AV could not find his/her way back to the facility. On or about June 27, 2024, AV eloped from the facility and was able to get into a bus. On or about June 28, 2024, AV once again eloped from the facility by bending a scree from a window and going through the window. Per an image provided during the investigation, the window AV eloped from does not appear to have any safe locking mechanism to prevent resident from opening the window and eloping. The facility failed to provide a safe environment for AV, leading to three (3) elopements in one (1) month, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of aggressive behaviors. On or about June 6, 2024, W1 was sitting in the dining room and Alleged Victim (AV) came up to W1 and said something. W1 and AV exchanged words which led W1 punching AV in the shoulder. On or about March 28, 2024, AV and W1 had a prior altercation. After the altercation from March 28, 2024, staff were to keep resident separated from each other. The facility failed to provide a safe environment to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be a known fall risk. AV’s service plan required staff to ensure AV used his/her walker at all times and if staff saw AV without his/her walker, staff were to get it for AV. On or about April 12, 2024, AV fell int the facility and as a result, he/she sustained a hip fracture which required surgery. At the time of the fall, AV’s walker was not within AV’s reach. Staff who had an opportunity to bring AV’s walker to AV just before the fall, had not reviewed AV’s service plan in six (6) months. The facility failed to assure AV’s service plan was being followed, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be in toileted every morning, before and after each meal, and at night before bed plus two (2) additional checks. Staff are to check on AV four (4) times per shift plus (three) 3 additional checks per shift for cleanliness. On or about April 12, 2024, AV was found with feces all over AV’s legs. On or about May 12, 2024, AV had once again been found multiple times with feces/urine all over the floor. The facility failed to follow AV’s service plan regarding his/her cleanliness, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is bedbound and per his/her service plan, requires eight (8) checks per shift. On or about January 22nd, 23rd, 24th and 25th, 2024, during the night shift, staff failed to check AV as required per the service plan. On or about February 5th, 6th, 7th, and 8th, 2024, during the night shift, staff failed to check AV as required per the service plan. As a result, AV suffered discomfort and skin breakdown. The facility failed to follow the service plan, resulting in skin breakdown to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for all of his/her care needs. On or about February 23, 2023, AV was transferred from the hospital to the facility with a stage 3 pressure ulcer to his/her sacrum. On that same day, the facility received medical records, including a copy of AV’s hospital after visit summaries. AV's after visit summary contained a referral and instruction to follow up with Amedisys Home Health for RN wound assessment, and specific wound care instructions for AV’s stage 3 pressure injury. Between February 23rd, through March 2nd, 2023, the facility failed to coordinate Home Health wound care services and the facility failed to provide wound care to AV. As a result, AV was transported to the hospital on March 3, 2023, where it was discovered that AV was diagnosed with a MRSA infection to his/her pressure ulcer. The facility failed to provide service around AV’s known would and would care, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be redirected by staff when needed. On or about September 30, 2022, AV eloped from the facility and was found three (3) blocks from the facility. AV followed a dishwasher out the kitchen door, the dishwasher stated he/she thought AV was a visitor. When AV was found, he/she stated he/she was freezing. The facility failed to follow the care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of aggressive behaviors and a history of altercations with Alleged Victim (AV). on or about July 29, 2022, W1 was having aggressive behaviors and striking at staff. W1 had also grabbed AV and caused a skin tear to AV, leaving a gash/abrasion to the right side, back of the hand to forearm. The facility failed to provide a safe environment to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) missed approximately four (4) doses of anti-seizure medication from February 1, 2022 – February 3, 2022, which resulted in AV having a seizure. The facility failed to provide a safe medication administration system to ensure Alleged Victim’s (AV) physician orders were followed and medications were reordered timely. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) service plan dated September 30, 2021, instructs staff to keep AV active during the day and to provide eight (8) safety checks per shift, and toileting AV four (4) times per shift. Between November 19, 2021, thru December 4, 2021, AV fell four (4) times, once while self-transferring from bed to the wheelchair, once at the floor of his/her bed, once on the floor of the bathroom, and once on the floor in front of the bathroom. There were no new fall prevention interventions noted for AV after these falls were noted, only the safe interventions as noted in AV’s September 30, 2021, service plan. The facility failed to care plan and mitigate AV’s risk of fall, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about January 1, 2022, AV informed staff that he/she had a bruise on his/her arm from staff gripping him/her too tightly when they picked him/her up. As a result, AV sustained a 3cm-by-3cm bruise on his/her left forearm. The facility failed to provide a safe environment to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure alleged victim (AV) medication was available to administer twice daily. AV went without anxiety medication December 6th. 7th, and 8th, of 2021 missing six consecutive doses, resulting in approximately three seizures on December 7th, 2021 causing the resident unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.

Alleged Victim (AV) was noted to be a fall risk on or about October 8, 2021, due to multiple diagnoses. However, no changes were made to AV’s care plan after a fall he/she sustained on or about October 8, 2021. On or about November 13, 2021, AV fell out of his/her wheelchair, as a result of the fall, AV sustained a 3 x 4-inch open scrape on his/her forehead, bruising on his/her breast and 2 black eyes. AV also showed signs of pain. The facility failed to properly plan care for AV and mitigate the risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administration Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Admonitive Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 05/01/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide service for the Alleged Victim, which is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

Alleged Victim (AV) relies on the facility for his/her care needs. Alleged Perpetrator 2 (AP2) was trained to know not to leave AV outside of memory care. AP2 took AV to bingo and left AV alone without checking on him/her. AP2 them left without telling staff that he/she took AV to bingo. AP2 failed to properly supervise AV, which is neglect of care and constitutes abuse. The facility failed to assure AV was supervised, which is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility allegedly failed to comply with the Monitoring requirements. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to administer medication as ordered for the Alleged Victim. There was no observable or documented evidence of a negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week. An investigation determined no licensing violation occurred.

Alleged Victim (AV) was on hospice and had a crushed medication order in place. Alleged Perpetrator 2 (AP2) forced a pill down AV’s throat after a crush was put in place and tried to give AV medication that had been discontinued. AP2 was witnessed not following orders. AP2 failed to follow the care plan around crushed medications for AV, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was being followed, which is a violation of Oregon Administrative Rules.

The facility allegedly failed to fully implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide services to assist the resident in activities of daily living including bathing and washing hair, and dressing and undressing in accordance with OAR 411-054-0030(1)(e)(B, D) per complaint that the facility fails to give regular showers as scheduled, and residents wear the same clothes for days on end.

The facility failed to post a copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable, which is a violation of Oregon Administrative Rules.

The facility failed to provide services to assist the resident in activities of daily living including toileting, showering, and dressing, which is a violation of Oregon Administrative Rules.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.

The facility failed to fully implement the Condition, which is a violation of Oregon Administrative Rules.

The facility failed to provide three daily, nutritious, palatable meals that are prepare and served in accordance with the food sanitation rules, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. Alleged Perpetrator 2 (AP2) has made AV feel small when he/she would see the mess AV has made. AP2 would use an elevated voice when talking to resident. AP2 would often withhold food and drink from AV after an accident. AP2’s failed to protect AV from emotional abuse, which is neglect of care and constitutes abuse. The facility failed to protect AV form emotional abuse, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is care planned to receive assistance with transfers. On or about March 1, 2022, staff found AV in his/her wheelchair fully dressed in a gait belt strapped to the front of his/her wheelchair, this would prevent AV to get up. Alleged Perpetrator 2 (AP2) stated that he/she placed the fait belt there so AV would not have a fall. AP2 failed to use restraint properly, which is neglect of care and constitutes abuse. The facility failed to assure the use of restraint properly, which is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents, which is a violation of Oregon Administrative Rules.