Print Violation: 00370978-AP-321307

Provider Information

Bonaventure of Tigard Memory Care

15000 SW HALL BLVD
Tigard, OR 97224

Date: 12/8/2024
Report number: 00370978-AP-321307
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: Alleged Victim (AV) relies on the facility for his/her care. AV has a known history of falls. On or about December 8, 2024, AV began to complain of severe pain on their left shoulder. AV’s shoulder was red, swollen, and hot to the touch. Staff reported AV’s service plan interventions were not being updated to reflect AV’s needs. AV was put to bed and woke up continuously in the middle of the night complaining of pain. The morning of December 9, 2024, AV was complaining of shoulder pain and was crying. Mid-morning on or about December 9, 2024, AV’s family was notified and was taken to the hospital where an unexplained injury was discovered, AV had a left humerus fracture. Respondent failed to provide a safe environment for AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00186 $500.00 fine assessed