Violation Details: 00435383-AP-387247

Records Request Print
Date
10/28/2025
Report number
00435383-AP-387247
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), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0055(1)(a-d) and (f)
Findings
The Alleged Victim (AV) relies on the facility to provide a safe medication administration system. According to an investigation, Alleged Perpetrator 2 (AP2) mixed AV's medications with AV's breakfast plate and left that plate with the facility kitchen staff. AP2 is required to administer medication to AV and not leave it until AP2 sees AV take the medication or properly dispose refused medications. The plate was given to another resident, Witness 1 (W1), who consumed AV's medications with the food. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rule. AP2 failed to provide a safe medication system for AV, which is considered neglect of care and constitutes abuse.