Print Violation: 00374352-AP-324709

Provider Information

Bonaventure of Tigard Memory Care

15000 SW HALL BLVD
Tigard, OR 97224

Date: 12/29/2024
Report number: 00374352-AP-324709
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(H)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) is a known fall risk and is to have stand by assistance with ambulation, ensure that AV has his/ her walker or wheelchair. On December 9, 2024, AV suffered a fall where he/she broke his/her arm. The facility didn't care plan around AV's broken arm or AV's inability to properly use his/her walker. On or about December 29, 2024, AV suffered a fall near the kitchen fire door, AV suffered nose swelling, facial bruising and lost 4 of his/her teeth and required medical attention from the dentist to receive partial dentures. Respondent failed to properly care plan to ensure AV's safety from falls, and to follow the care plan to have stand by assist with ambulation. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00157 $375.00 fine assessed