Violation Details: 00412267-AP-363481

Records Request Print
Date
7/6/2025
Report number
00412267-AP-363481
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
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: 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, on or about July 6, 2025, Alleged Perpetrator 2 (AP2) administered AV medications not prescribed to AV. AV experienced side effects due to the medication error. AP2's actions are considered neglect and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.