Print Violation: 00396314-AP-347003

Provider Information

Bonaventure of Tigard Assisted Living

15000 SW HALL BLVD
Tigard, OR 97224

Date: 4/3/2025
Report number: 00396314-AP-347003
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)(e) and (g), (4)(a)
External site: 411-054-0055(1)(a) and (f)
Findings: The Alleged Victim (AV) was sent to the hospital on 3 occasions due to not being on oxygen as required by his/her physician. AV was to wear oxygen at all times, and staff should have been checking AV every 2 hours to ensure that AV's oxygen was on and working. AV's service plan was not updated to reflect to all staff that AV should have oxygen at all times. AV experienced unreasonable discomfort from the facility not ensuring that AV had oxygen available at all times. Respondent failed to ensure AV's care plan was properly updated to reflect AV's current needs, which posed a risk of serious harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction: ALFCP26-00067 $500.00 fine assessed