Print Violation: 00165889-AP-131569

Provider Information

Bonaventure of Tigard Memory Care

15000 SW HALL BLVD
Tigard, OR 97224

Date: 10/18/2021
Report number: 00165889-AP-131569
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: The Facility failed to follow the Alleged Victim’s (AV) care plan to know his/her whereabouts at all times, and failed to maintain a functional door alarm to mitigate the risk of elopement. The failure resulted in AV eloping the secured facility and being found outside on the ground with a severe head injury requiring hospitalization, and the AV passed away approximately 17 days after the incident. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP22-01072 $2500.00 fine assessed