Print Violation: 00388674-AP-339165

Provider Information

Washington Gardens Memory Care

9000 SW 91ST AVENUE
Tigard, OR 97223

Date: 3/11/2025
Report number: 00388674-AP-339165
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: 411-054-0036(2)(g)
External site: 411-054-0040(1)(b) and (c)
Findings: The Alleged Victim (AV) had a history of falls. On or about March 11, 2025, AV was found on the floor in front of his/her recliner. Staff had last checked on AV and offered to re-position AV in his/her recliner, however, AV declined repositioning. AV was reported to have a significant change of condition regarding mobility, however, no documentation was completed to ensure the facility was addressing AV's changing needs. AV's care plan was not updated nor were any new interventions put into place between January 15, 2025 and March 9, 2025 when AV was experiencing an increase in falls. After AV's fall on March 11, 2025, AV was sent to the hospital and diagnosed with a fractured rib and a red mark on AV's forehead. The facility's failure to properly care plan regarding AV's risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP25-01152 $375.00 fine assessed