Bonaventure of Salem Memory Care

The Alleged Victim (AV) moved into the facility on August 23, 2024, and had eloped from a previous residence. Between August 25, 2024, and August 28, 2024, AV was actively exit seeking and did elope from the facility twice in one day. The facility failed to place AV on alert charting for elopement risk, placing AV at risk for harm. The respondent's failure to provide a safe environment and actively care plan to prevent AV from eloping the facility placed AV at risk for harm.

The Alleged Victim (AV) moved into the facility on August 23, 2024, and had eloped from a previous residence. Between August 25, 2024, and August 28, 2024, AV was actively exit seeking and did elope from the facility twice in one day. During the elopement, AV fell from his/her wheelchair three times. The respondent's failure to provide a safe environment and prevent AV from having falls placed AV at risk for harm.

Alleged Victim (AV) is known to have a history of falls. Between February 10, 2024, through March 6, 2024, AV sustained 13 falls, with multiple falls in one day on three (3) occasions. On or about March 6, 2024, AV had an unwitnessed fall in the common area which resulted in a broken collar bone and pain to AV. The temporary care plan did not include new fall interventions that were put into place for AV. The facility failed to care plan and mitigate AV’s risk of falls, 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 11, 2024, it was reported that Alleged Perpetrator 2 (AP2) threw food down in front of AV and told AV, “I hope you choke on it.”. There have been prior complaints in the past regarding the way AP2 talked to residents, but the facility did not take any action towards AP2. AP2 failed to protect AV from mental abuse, which is neglect of care and constitutes abuse. The facility failed to protect AV from mental abuse, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states AV will go to the double doors and push on them; staff are to walk around the community with AV. On or about October 14, 2023, AV stepped out of the building when AV saw an opportunity. As a result, AV eloped from the secure unit of the memory care facility. AV was found outside the front door of the assisted living facility. The facility failed to follow the care plan by not having a staff member walk around AV putting AV in risk of harm, which resulted in AV eloping, which is ai violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) as a known history of wondering into other resident’s rooms on a daily basis. On or about September 10, 2023, AV wondered into Witness 1’s (W1’s) room. AV’s family said they witnessed AV walk into W1’s room. While in W1’s room, AV stated W1 was pulling AV and grabbing AV. As a result of the altercation, AV sustained a fall. AV has been involved in four (4) other altercations due to his/her wandering. AV’s service plan states he/she is to be escorted by staff to and from all meals to prevent altercations, however, staff do not always escort AV to and from meals, putting AV in risk of harm. The facility failed to follow AV’s service plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of resident-to-resident altercations. On or about May 31, 2023, Alleged Victim (AV) and W1 were involved in an altercation leading to AV sustaining a large skin tear to his/her arm. The altercation occurred outside their room. AV has a known history of wondering into other resident’s rooms and W1 does not like any residents going into his/her rooms. The facility failed to provide a safe environment for AV, leading AV to sustained harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states AV is to have Tubigrips on his/her calves to protect them from skin tears. On or about May 29, 2023, AV did not have his/her protective covering on his/her calves and as a result, AV sustained a skin tear on his/her lower legs. The facility failed to follow AV’s care plan putting AV is risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Progress Notes from May 24, 2023, outlines Alleged Victim (AV) is weak related to a prior hip fracture. Between May 24th through June 6, 2023, AV fell six (6) times in the memory care unit. As of May 30, 2023, there were no fall interventions implemented after a fourth (4th) fall. There were no new fall interventions implemented after AV’s fifth (5th) and sixth (6th) fall that occurred on or about June 3rd and 6th, 2023. As a result of the falls, AV sustained skin injuries. The facility failed to care plan appropriately 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 history of going into other resident rooms and being aggressive towards other residents. On or about May 18, 2023, W1 went into Alleged Victim’s (AV’s) room, hit the side of AV’s head, and grabbed AV’s walker. Interventions have not been put in place to keep W1 from hurting other residents, knowing he/she has a history of doing so. The facility failed to care plan around W1’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) is known to not like people in his/her space, and to be territorial and has a chair in front of his/her room but gets mad when wanderers are there. On or about March 25, 2023, Alleged Victim (AV) was found in the entrance of W1’s apartment on the floor. AV was knocked to the ground by W1 and as a result, he/she sustained a bruise on the right eye. AV and W1 have been in prior altercations. W1 has been in prior altercations in which other residents have sustained injuries. The facility failed to provide a safe environment for AV, which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to wonder checking doors to see if they are open. On or about March 24, 2023, Witness 1 (W1) found AV sleeping in their bed. W1 became frustrated and started to yell at AV. W1 then scratched AV on the cheek. This is not the first resident to resident altercation between AV and W1. There was a prior altercation between AV and W1 on or about March 1, 2023, in which AV wandered into W1’s room and W1 grabbed AV’s arms and scratched AV’s face. A statement from Witness 5 (W5) stated that after searching, he/she could not find any interventions in place to prevent resident to resident altercation between AV and W1 after the incidents from March 1st and 24th, 2023. The facility failed to properly plan care around AV and W1’s known history of altercations, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to wonder into other resident’s rooms. On or about March 1, 2023, AV wandered into Witness 1’s (W1’s) room, W1 then became upset and grabbed AV and scratched AV. W1 has been involved in prior altercations with other residents before, there is a TSP for a prior incident of an altercation, however, that TSP does not indicate any interventions for staff. W1’s care plan notes under the question: Does W1 become easily angered requiring interventions to prevent harm to others, the response indicated “No”. The facility failed to properly care plan around W1’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is cared planned as a not at risk of elopement person. On or about October 12, 2022, a landscaper was walking into the facility and AV walked out. This has not been the only occasion in which AV has eloped. AV also eloped on or about July 15th and 21st, and August 2nd and 12th, 2022. There is no indication the care plan had been updated to add proper interventions regarding AV’s elopement history. The facility failed to care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of physical aggression towards other residents. On or about September 4, 2022, W1 kicked AV in the leg after seen AV become aggressive towards a staff member. W1 has kicked AV previously and has a history of resident-to-resident altercations. The facility failed to provide a safe environment for AV, 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 August 26, 2022, AV touched Witness 1 (W1) and W1 reacted by hitting AV. W1 has been in a prior altercation on or about August 12, 2022, with another resident and there was no temporary service plan in place to prevent harm from happening again to another resident. The facility failed to provide a safe environment for AV, 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 needs. On or about July 30, 2022, AV was found with a cut/skin tear to his/her elbow. AV previously had skin tears or bruising on May 16th, June 18th, July 6th, 16th and 21st, 2022. There is no documentation in chart notes or incident reports of any new or different interventions being implemented in June or July to prevent future skin issues. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of skin injuries, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of wandering into other resident rooms. On or about June 26, 2022, W1 knocked on the AV’s door and got into a resident-to-resident altercation. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has known exit seeking behaviors. AV has eloped from the facility on May 27th, June 4th, and June 23rd, 2022. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about May 25, 2022, AV fell out of bed and was found sitting on the ground. AV’s service plan date February 4, 2022, outlined that AV was a fall risk and that AV has had many falls prior. AV had fallen out of bed on or about March 5, 2022, fell out of a chair on March 24, 2022, and fell out of another chair on March 26, 2022. AV then fell out of bed again on May 12, 2022. There is no documentation of any new fall interventions being put in place after AV’s recent falls. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of bruising and skin tears. AV has pads on his/her wheelchair to help prevent injury but will pull the pad off. AV has had two (2) previous injuries to his/her leg and there have been no new interventions added. The facility failed to care plan around AV removing the pad to the wheelchair, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of bruises and skin tears. AV wears protective sleeves over his/her arms to prevent injuries but he/she is able to take off the protective sleeves and will not always be waring them. AV has continued to have injuries to his/her arms with the current interventions in place. The facility failed to care plan around AV removing the sleeves from his/her arms, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of lower leg bruising. On or about May 16, 2022, staff noticed two small discolorations to the front and back of AV’s right lower leg. No interventions were implemented after a prior incident from February 5, 2022. The facility failed to properly plan care, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has implemented interventions to make sure he/she has TED anti-embolism stockings on to prevent bruising. On or about June 4, 2022, staff noticed a new purple discoloration on AV’s front lower leg. It has been in AV’s service plan to wear ted hose since November 27, 2021; however, AV has sustained at least three (3) lower leg bruises since November 2021. The facility failed to provide a safe environment for AV, 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. Between February 2022 to May 3, 2022, AV has been found with skin tears, bruising and/or abrasions on his/her arms or legs on 13 occasions. On or about May 2, 2022, AV was found with a very deep skin tear to the head which required stiches. AV continued to have injuries and no new interventions were noted after every occurrence to prevent new injuries. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. Between March 29th, through April 14th, 2022, AV suffered 12 falls, several falls with injury, including a nasal bone fracture. On or about April 17, 2022, AV fell twice, once in the dining room and once in the activity room. The facility failed to appropriately and implement interventions to 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 receive one-person assist for all mobility and transfers. AV often attempts to transfer and ambulate without assistance. AV fell on April 4th, 5th, 6th, 11thand 17th, 2022, while unsupervised by staff. The facility failed to provide a safe environment for AV, 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. Between March 14th, through April 6th, 2022, AV had sustained or had been found on the floor approximately eight (8) times, some falls resulting in injury. AV has received several bruises and skin tears as well as a broken nasal bone, a pelvic contusion, and a sprained shoulder from the falls sustained. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to appropriately care plan for the alleged victim (AV) regarding his/her risk of falls. AV was found on the floor from a fall at least seven times between January 1st, 2022 and March 20th, 2022, no new interventions were put in place to mitigate AV’s fall risk. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (VA) has a history of altercations with Witness 1 (W1) which have taken place on or about May 14th, July 6th, and November 19, 2021. On or about March 3, 2022, staff heard a noise in the dining room, staff found AV pulling on W1’s wrist and arm. W1 had started to pick up cups and AV did not like that W1 was picking up the cups and so begun to grab and pull W1’s wrist and arm. The facility failed to provide a safe environment for W1 and putting W1 in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse. The facility failed to care plan arounds AV’s known history of altercations, which is a violation of resident rights is neglect of care and constitutes abuse.

Witness 1 (W1) and Alleged Victim (AV) have been involved in resident-to-resident altercation on or about May 14th, July 6th, and November 19, 2021. On or about March 3, 2022, staff heard a noise in the dining room, staff found W1 pulling on AV’s wrist and arm. AV had started to pick up cups and W1 did not like that AV was picking up the cups and so begun to grab and pull AV’s wrist and arm. The facility failed to provide a safe environment for AV and putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of bruising and skin tears due to his/her removing protective sleeves on his/her arms and pads on his/her wheelchair. AV has been found with injuries on his/her lower arm and/or back of his/her legs on or about February 4th, 19th and 22nd, 2022, and no new interventions have been implemented to prevent new injuries. The facility failed to care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of injuries of unknown cause including skin tears and bruising. Between December 23, 2021, through February 23, 2022, AV suffered numerous falls, bruises, and skin tears. AV’s service plan was updated on January 21, 2022; however, it did no list specific interventions designed to reduce or prevent future injuries. AV suffered skin tears or bruising on or about January 28th and 29th, 2022, February 2nd, 12th, and 19th, 2022. The facility failed to properly care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. Between October 24, 2021, through December 24, 2022, AV suffered four (4) falls in his/her room, some resulting in injuries. On or about January 18, 2022, AV fell in his/her room, suffering an abrasion to his/her right leg. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) is known to have aggressive behaviors. On or about October 31, 2021, W1 was showing aggressive behaviors. W1 kicked Alleged Victim and then punched a staff member. The facility failed to care plan related to W1’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to follow Alleged Victim’s (AV) care plan to complete safety checks every 30 minutes when AV is in his/her room, due to fall risk. On or about October 28, 2021, AV had an unwitnessed fall, resulting in elbow pain. The failure is a violation of resident rights, is considered neglect of care which constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Between September 9 through October 12, 2021, AV sustained approximately ten (10) falls and had sustained injuries from the falls. On or about October 25, 2021, at around 2:15 am, AV was found on the floor in his/her room between the bed and the bathroom. AV had sustained another fall the day before, on October 24, 2021. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, 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 October 19, 2021, AV was found on the floor with a 5cm skin tear on his/her arm after he/she rolled or fell out of bed. AV had previously rolled/fell out of bed on October 15th and 17th, 2021, which both resulted in injury. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a fall risk resident. Between August 20th, through October 15, 2021, AV sustained falls or was found on the floor on six (6) occasions, most incidents resulted in injury to AV. On or about October 15, 2021, AV was found on the floor, AV had an abrasion on this/her left big toe and skin tear on his/her private area. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

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 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 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 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 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 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 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.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Facility was not sufficiently staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents on September 7, 2024. 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.

According to the documentation, the Alleged Perpetrator (AP2) failed to follow the care plan for the Alleged Victim (AV) when assisting with a hoyer transfer. The failure resulted in the AP2 to self-transfer the AV by themselves resulting in the AV to suffer a fall, which is a violation of resident rights and is considered abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that from 05/10/23 to 05/12/23 a resident did not receive their medications.

The facility failed to provide services to assist the resident in activities of daily living including personal hygiene and grooming in accordance with OAR 411-054- 0030(1)(e)(C) and (E) per complaint that the resident is not shaved daily, and the facility has not arranged for the resident's toenails to be trimmed.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complainant that the facility did not have any swing or noc caregivers and the receptionist had to cover memory cover.

The facility failed to fully implement the Condition in accordance with OAR 411-054-0110.

Alleged Victim (AV) relies on the facility for his/her care. On or about August 2, 2022, AV was waiting at the front desk to leave for an appointment and left the facility and was found 15 minutes later down the road from the facility on the street. Alleged Perpetrator 2 (AP2) knows that there is supposed to be a staff with AV when he/she is waiting to leave the facility but got distracted and did not see AV leave the facility. AP2 failed to provide a safe environment for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

The facility failed to prepare and serve food in accordance with Food Sanitation Rules as required by OAR 411-054-0030(1)(a)(C) per complaint that food is served under temperature and plates are being sent out with old food still stuck on them.

Based on interview, observation and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: CS observed that the facility does not have a posted staffing plan. Schedule for July and August reflects staffing levels listed in the Uniform Disclosure Statement (UDS). Interview with Staff #1 on 07/13/2022 stated the facility has not implemented the ABST. Will be using ODHS tool. Has put a few residents in the system. Is currently staffing to the level listed in the UDS. Stated there are around 5 or 6 2-person transfers.

Alleged Victim (AV) is care planned to be a two person assist in transferring. On or about July 8, 2022, AV needed to be changed and Alleged Perpetrator 2 (AP2) decided to transfer AV by him/herself. As a result, during the transfer AV put his/her legs out and this caused AP2 to drop AV and hitting his/her head. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure AV’s care plan was being followed, which is a violation of Oregon Administrative Rules.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that there is sometimes only one staff working with multiple two-person assist residents in the facility.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents in accordance with OAR 411-054-0025(4) per complaint that staff do not wear masks in the facility and there is box screens and/or mattress leaning against the wall in residents room causing a potential trip hazard and there are chemicals in an open and unlocked salon.

The facility failed to provide a daily program of social and recreational activities in accordance with OAR 411-054-0030(1)(c) per complaint that there are no activities in the facility.

The facility failed to provide a daily program of social and recreational activities in accordance with OAR 411-054-0030(1)(c) per complaint that there are no activities in the facility.