Print Violation: 00459550-AP-429167

Provider Information

The Watermark at The Pearl

1540 NW 13TH AVE
Portland, OR 97209

Date: 2/24/2026
Report number: 00459550-AP-429167
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide oversight and monitoring of change of condition
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) relies on the facility for medication and treatment management. The AV required weight monitoring and had specific parameters for reporting weight changes to the AV's provider to direct medication adjustment. According to an investigation, on multiple occasions the AVs weight was documented as meeting the parameter for reporting to the medical provider as ordered. There was no evidence the increase in weight was reported, placing the AV at risk of medical complications. On March 16th, 2026, the AV's medical provider adjusted a medication dosage. The new dosage was not initiated until March 19th, 2026, and the medication was not administered on March 18th, 2026, placing the AV at risk of medical complications. The allegation that Alleged Perpetrator failed to follow medical orders was investigated and determined to be not substantiated. The facility failed to follow medial orders and administer medication as ordered for the AV, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.
Sanction: RCFCP26-00631 $225.00 fine assessed