Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00465565-AP-417915
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
- 3/22/2026
- Report number
- 00465565-AP-417915
- 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)
411-054-0055(1)(a) and (f)
- Findings
- On or about March 22, 2026, the facility failed to administer the Alleged Victim’s (AV) newly prescribed medication. AV is a resident of the facility, and the facility is responsible for administering all of AV’s prescribed medications. Based on facility documentation and staff interviews, AV returned from the hospital on March 21, 2026, with medication changes that included discontinued medications and new medication orders. On March 23, 2026, the facility discovered that these new medication orders had not been properly entered into AV’s Medication Administration Record (MAR). As a result of this error, AV’s medications were not administered as ordered, causing unnecessary discomfort, including a weight gain of more than four pounds in a short period of time. According to the Risk of Harm Letter collected during the investigation, missing these medications could pose a Serious Risk of Harm or Decompensation due to the potential for an abrupt and serious worsening of health requiring urgent medical attention. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP26-00457 $500.00 fine assessed