Print Violation: 00454148-AP-406235

Provider Information

Washington Gardens Memory Care

9000 SW 91ST AVENUE
Tigard, OR 97223

Date: 1/27/2026
Report number: 00454148-AP-406235
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate 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)
Findings: The Alleged Victim (AV) is care planned as independent with mobility, however, requires a one-person standby assist for transfers. AV has a history of inconsistent walker use, which has been identified as a contributing factor in prior falls. On or about January 27, 2026, AV was found on the floor by care staff. AV suffered an abrasion and bruising to his/her right shoulder and expressed pain. At the time of this incident, AV had been identified as a low fall risk and therefore did not have fall preventions in place. Respondent failed to ensure proper care planning to reduce the risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00495 $500.00 fine assessed