- Date
- 12/3/2025
- Report number
- 00443168-AP-395158
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to protect resident from financial exploitation
- Result
- Substantiated
- Findings
- Alleged Victim (AV) resides in the Respondent’s facility and depends on the facility for assistance with activities of daily living and medication administration. AV is prescribed narcotic pain medication. Alleged Perpetrator 2 (AP2) completed all required medication-technician training provided by facility staff. AP2 has a history of prior disciplinary action related to medication errors, including inaccurate charting and missing documentation. Despite this, the facility failed to maintain a safe medication administration system and did not provide adequate oversight or monitoring of AP2 following the disciplinary action issued on November 7, 2025.
On or about December 8, 2025, Witness 2 (W2) identified discrepancies in the narcotic log for AV’s PRN pain medication. AP2’s narcotic count was incorrect; AP2 documented that 9 pills remained when the log indicated there should have been 10. Upon W2’s count, only 8 pills were found in the bottle. AP2’s actions constitute a violation of resident rights and are considered neglect of care, as well as financial abuse. The Respondent’s failure to ensure a safe medication administration system constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(ii).
- Sanction
- RCFCP26-00550 $188.00 fine assessed