Violation Details: 00439475-AP-391294

Records Request Print
Date
11/13/2025
Report number
00439475-AP-391294
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide proper food/nutrition
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)(a) and (b)
411-054-0030(1)(a)(A-C)
411-054-0036(2)(g)
Findings
Alleged Victim (AV) lived at Respondent’s facility. There is a whiteboard in the kitchen where all the residents are listed with food allergies, and dietary restrictions. AV's service plan reflects that AV has an intolerance to eating mushrooms, which causes severe stomach cramping and diarrhea. Facility staff are to ensure that mushrooms are not served to AV. On or about November 13, 2025, AV was served and ate mushroom soup at dinner. As a result, AV had cramping and diarrhea. Respondent failed to develop and ensure modified special diets for residents' needs and choices were followed. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(A)(i). The allegation that AP2 neglected AV by feeding AV mushrooms was investigated and determined to be Not Substantiated.
Sanction
RCFCP26-00648 $450.00 fine assessed