- Date
- 11/21/2025
- Report number
- 00440835-AP-392779
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Alleged Victim (AV) cognitively doesn't understand that AV has problems and is very forgetful. AP2 had prepared the health shake for another resident and then turned around. AV may have drank the shake and is allergic to the medication. W1 was called and advised "send AV to the ER immediately." AP2 made a medication shake for another resident and handed it to that resident. AP2 became distracted by another resident that was about to have an "episode." When AP2 turned around, the shake was gone and sitting on a table next to AV. AP2 failed to provide a safe environment for AV, which is neglect of care and constitutes abuse. The facility failed to ensure AV received a safe environment, which is a violation of Oregon Administrative Rules.