Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00298247-AP-251745
Provider Information
Bonaventure of Gresham Memory Care
22514 SE STARK STREET
Gresham, OR 97030
- Provider ID
- 50R442
- Administrator
- Toni Gossard
- Phone
- (503) 328-0010
- memorycaregre@livebsl.com
Violation Details
- Date
- 11/23/2023
- Report number
- 00298247-AP-251745
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- 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
- Alleged Victim’s (AV’s) care plan stated AV is a fall risk, staff are to regularly check on AV, AV requires a one-person transfer for toileting. On or about November 22, 2023, at about 10:00 pm, care staff working the swing shift left the facility and care staff working the overnight shift began working. At this point, a “shift change meeting should have taken place so that outgoing staff and incoming staff would move from room to room to discuss the current issues and care needs for residents. During the regularly scheduled rounds, overnight shift staff observed AV’s room to be empty, and AV’s bed to be made. There were no further checks on AV during the entire night shift. On or about November 23, 2023, at about 6:00am the morning shift care staff arrived, and overnight shift care staff informed morning shift staff that they had not seen AV, and they assumed AV was likely outside of the facility visiting family. At approximately 8:30am, AV was found in a locked bathroom in the common area of the facility. AV was found on the floor of the bathroom located between the wall and the toilet. As a result of the fall, AV expressed pain for multiple days. The facility failed to follow AV’s care plan regarding regular check on AV and by failing to assist AV with a one-person transfer for toileting, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00390 $375.00 fine assessed