Print Violation: 00333104-AP-284269

Provider Information

Courtyard at Mt Tabor Garden House

6323 SE DIVISION
Portland, OR 97206

Date: 5/24/2024
Report number: 00333104-AP-284269
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) relies on the facility to administer his/her medications. On or about May 23rd and 24th, 2024, AV was administered (blood pressure medication #1) and (blood pressure medication #2). The order to discontinue (blood pressure medication #1) was misplaced and was located after AV had already received blood pressure medication #1 in error on or about May 23rd and 24th, 2024. As a result, AV had a fall on May 23rd and 24th, 2024, in which AV sustained injuries. AV’s primary care team discontinued both blood pressure medications due to AV having side effects and resulting in falls. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00147 $500.00 fine assessed