Violation Details: 00459584-AP-411917

Records Request Print
Date
11/20/2025
Report number
00459584-AP-411917
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide service
Result
Substantiated
Rule(s) Violated
411-054-0025(b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility for their care. AV had an order for a pureed diet with nectar thick liquids. According to an investigation, AV’s care plan and Medication Administration Record (MAR) was not updated to reflect the order for diet with nectar thick liquids and AV was given unthickened liquids on two occasions in November 2025, posing a risk of harm. The facility failed to provide appropriate services, related to appropriately planning care, proving a safe medication administration and administering medications as ordered, which is a violation of resident rights, is neglect of care and constitutes abuse as defined in OAR as defined in 411-020-0002(1)(b)(A)(ii).
Sanction
RCFCP26-00581 $500.00 fine assessed