Violation Details: 00440024-AP-391885

Records Request Print
Date
11/11/2025
Report number
00440024-AP-391885
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)(a) and (b)
External site: 411-054-0030(1)(e)(f)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a), (c), and (f)
Findings
Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medications were administered as ordered. On or about November 11, 2025, two of AV’s medications were found on the floor of the activity room where AV was attending activities. AV requires AV’s medication to be crushed, not given whole. Staff are instructed to observe residents taking their medication during administration. AV did not receive medications as order, AP2's actions placed AV at risk of serious harm, are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.