Print Violation: 00155877-AP-123513

Provider Information

Pioneer Village

805 N 5TH ST
Jacksonville, OR 97530

Date: 8/16/2021
Report number: 00155877-AP-123513
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)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) is known to choke on his/her food due to a stroke, and his/her food is to be cut up into small pieces to avoid choking. AV's care plan did not indicate the necessity of cutting up AV's food, however, there was information in the kitchen regarding AV's choking issue. On or about August 16, 2021, AV was given food that was shredded instead of cut into small pieces, causing AV to choke. Staff had to perform the Heimlich maneuver, which did not work and Emergency Services were called in. AV passed the food and was sent to the hospital to ensure all was ok. AV was not harmed from this incident, however, AV was placed at risk for serious harm. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP21-03230 $188.00 fine assessed