Violation Details: 00441716-AP-393704

Records Request Print
Date
11/27/2025
Report number
00441716-AP-393704
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) and (f)
Findings
Alleged Victim (AV) lives at Respondent’s facility. Facility staff are to order, manage and administer all AV medications. AV is scheduled to be administered a neurological medication at 2:00am each night. The facility had received complaints the week of November 27, 2026, that Alleged Perpetrator 2 (AP2) was not available or helpful. Witness 3 (W3) went to the facility on November 27/25 at 3:15am for a random check-in with staff, found AP2 sleeping on a sofa during their shift. Medication audit discovered AV had several late medication passes when AP2 was working. AP2 did not administer AV's medications timely 12 days in the month of November. AP2's actions 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.