Print Violation: 00383974-AP-334512

Provider Information

Riverview Terrace

1970 WEST HARVARD AVENUE
Roseburg, OR 97471

Date: 2/14/2025
Report number: 00383974-AP-334512
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation: Failed to follow care plan
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: 411-054-0030(1)(a)(A)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) lives at the facility and is care planned for a modified diet. AV requires steak to be cut up into small pieces, which is to be completed by facility staff. On or about February 14, 2025, AV was served steak in his/her room for his/her meal by staff. Staff delivered the meal and continued to deliver other residents meals. AV was sitting in the hallway by his/her room when staff found AV unconscious. Staff began Heimlich maneuver, abdominal thrust and mouth sweep and called emergency services. AV was intubated and transferred to the hospital. AV passed away at the hospital two days later. Respondent failed to ensure staff followed the service plan to cut up AV's steak in smaller pieces, which caused AV to choke. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00050 $1500.00 fine assessed