Violation Details: 00433952-AP-402269

Records Request Print
Date
10/21/2025
Report number
00433952-AP-402269
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
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
On November 1, 2025, ODHS Adult Protective Services (APS) conducted investigation #00433952 and issued a written investigation report, which is incorporated here by reference. The Alleged Victim (AV) is a resident of the facility and under its care. The facility is responsible for managing and administering all of AV's prescribed medications, including pain medication scheduled at 8:00 AM, 12:00 PM, and 4:00 PM daily. Based on interviews and record review, it was determined that the facility failed to administer pain medication as ordered: - 09/24/2025: Missed 4:00 PM dose. - 09/25/2025 – 09/28/2025: No doses administered. - 09/29/2025: Missed 8:00 AM dose. The facility failed to provide a safe medication administration system to ensure AV's pain medications were administered as ordered which resulted in AV experiencing continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse
Sanction
ALFCP26-00061 $500.00 fine assessed