- Date
- 11/7/2025
- Report number
- 00438350-AP-390141
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On January 27, 2026, ODHS Adult Protective Services (APS) completed investigation #00438350 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. Facility staff is responsible to administer AV"s medications as prescribed. On or about November 7, 2025, the Alleged Victim (AV), received an incorrect dose of prescribed medication. Facility staff were responsible for administering AV’s medications as ordered. AV was prescribed 1 mg of an anxiety/agitation medication but was instead administered 2 mg. As a result of the medication error, AV experienced three falls on the same day in which one of these falls caused AV to sustain a hematoma to the forehead. The facility's failure to provide a safe medication administration system to mitigate risks resulted in AV experiencing unreasonable and unnecessary discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP26-00153 $500.00 fine assessed