Print Violation: 00322916-AP-274703

Provider Information

Courtyard at Mt Tabor Garden House

6323 SE DIVISION
Portland, OR 97206

Date: 4/3/2024
Report number: 00322916-AP-274703
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(a)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(I)
Findings: The Alleged Victim (AV) is a known fall risk, typically sliding from his/her wheelchair onto the floor. On or about April 3, 2024, staff noticed multiple bruises on AV and sent him/her out to the hospital for evaluation. AV had bruising on his/her chest, shoulder, right arm and both knees. AV was also noted to have a broken bed, where staff could not lower the bed to the lowest position, it was stuck at the highest position. AV's bed was to be in the lowest position and could not be due to it being broken. The facility failed to provide a safe environment for AV, resulting in bruises to his/her body. Respondent failed to ensure a safe environment. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00087 $250.00 fine assessed