Print Violation: 00387039-AP-337529

Provider Information

Courtyard at Mt Tabor Pavilion

2350 SE 60TH AVE
Portland, OR 97206

Date: 2/26/2025
Report number: 00387039-AP-337529
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
Findings: Alleged Victim (AV) relies on the facility for his/her care. On or about February 26, 2025, AV was signed out of the secure unit by Alleged Perpetrator 2 (AP2) at 10:45 am. AV was brought to the exercise class in the unsecure part of the building where AV resides. While under the care of AP2, AV visited the apartment of Witness 4 (W4) and Witness 5 (W5). AV was not accompanied by AP2. While visiting W5, AV was responsible for a physical injury to W5. AP2 was provided with training in regard to supervision of memory care residents and understood that there was an expectation that maintaining a line of sight with AV was necessary to fulfill the monitoring expectation. AP2 failed to assure resident was safe, which is neglect of care and constitutes abuse. The facility failed to assure resident was safe, which is a violation of Oregon Administrative Rules.