Print Violation: 00424083-AP-375569

Provider Information

Awbrey Place Memory Care

2825 NEFF RD
Bend, OR 97701

Date: 8/24/2025
Report number: 00424083-AP-375569
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: The Alleged Victim (AV) relied on the facility for care and medication administration. According to an investigation, there were multiple medication and documentation errors in AV's pain patch administration by multiple facility staff between August 6, 2025, and August 15, 2025. On or about August 12, 2025, AV displayed out of character aggravation and irritation after missing their fentanyl patch change scheduled for that day. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP26-00409 $500.00 fine assessed