Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00455553-AP-407696
Provider Information
Still Waters Inc
475 ELMIRA AVE SE
Bandon, OR 97411
- Provider ID
- 50R496
- Administrator
- Dominique Palmer
- Phone
- (541) 329-2183
- dominique@stillwatersinc.info
Violation Details
- Date
- 10/3/2025
- Report number
- 00455553-AP-407696
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious 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)
411-054-0030(1)(e)(I)
411-054-0036(2)(g)
411-054-0040(1)(a) and (d)
411-054-0055(1)(a) and (f)
- Findings
- In the month of October 2025, the facility failed to provide a safe medication administration system for the Alleged Victim (AV) which resulted in several lapses of AV's psychotropic medications. AV was admitted to the facility on or about September 3, 2025, with a long-standing history of significant mental health conditions. According to facility documentation and interviews, AV's mental health was stable at time of being admitted to the facility. In early October 2025, AV began exhibiting acute psychiatric deterioration, including hearing voices and experiencing fear, sadness, and agitation. According to facility documentation, AV experienced multiple lapses in prescribed psychotropic medications due to the medications being unavailable and/or lacking timely refill requests: • Medication #1: 10-day lapse (10/6–10/15); Medication #1 was requested for refill on 10/15. The same date the prescriber signed the order. • Medication #2: 14-day lapse (10/3–10/16); Medication #2 was requested for refill on 10/17. The same date the prescriber signed the order. • Medication #3: 14-day lapse (10/3–10/16); Medication #3 was requested for refill on 10/15. The same date the prescriber signed the order. • Medication #4: 4-day lapse (10/3–10/6); Medication #4 was requested for refill on 10/6. The same date the prescriber signed the order. • Medication #5: 5-day lapse (10/2–10/6); Medication #5 was unavailable and/or needing a new script. According to facility documentation, there was no documentation showing staff attempted to request AV's refills one week prior to medications running out, as required and late refill requests were not initiated timely. Staff were unable to explain why AV went without these medications for extended periods. AV showed signs of significant behavioral changes that would negatively impact AV's safety and the safety of other residents at the facility. On October 26, 2025, AV vocalized suicidal ideation with a plan of action to light AV's self on fire and on October 31, 2025, AV made the following statement to his/her medical provider, " I am not in my right mind. I feel like I'm going to hurt someone". AV presented as mentally and emotionally stable upon admission to the facility on September 3, 2025. Within less than 45 days of admission, AV experienced a significant decline in mental health functioning, evidenced by symptoms consistent with his/her diagnosed mental health conditions, including but not limited to hallucinations, suicidal ideation, agitation, and expressed intent to harm others. The facility's failure to mitigate a lapse of medications prescribed to stabilize AV's mental health resulted in unnecessary and unreasonable discomfort and a serious loss of personal dignity which is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- RCFCP26-00480 $1500.00 fine assessed