Print Violation: 00081632-AP-060639

Provider Information

Tabor Crest Ii Memory Care

16050 NE HALSEY STREET
Portland, OR 97230

Date: 4/29/2020
Report number: 00081632-AP-060639
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation: Failed to assure food safety
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0030(1)(a)(A)
Findings: Alleged Victim (AV) has an order for thickened liquids. On or about April 29, 2020, Alleged Perpetrator 2 (AP2) gave AV a drink of thin liquids during medication administration in the dining room causing AV to aspirate. AV was transported to the emergency room, diagnosed with aspiration pneumonia and later passed away. The facility did not have any documented procedures in place to ensure residents requiring thickened liquids were served appropriate drinks in the dining room. The facility failed to assure food safety, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP20-00911 $2500.00 fine assessed