Violation Details: 00435385-AP-387238

Records Request Print
Date
10/28/2025
Report number
00435385-AP-387238
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
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 medication into AV's meal and left the meal unattended with the kitchen staff. As a result, AV did not receive AV's medications as prescribed. 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 a violation of resident rights and is neglect which constitutes abuse.