Violation Details: 00445818-AP-414642

Records Request Print
Date
12/16/2025
Report number
00445818-AP-414642
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
411-054-0025(1)(a) and (b)
411-054-0055(1)(a) and (f)
Findings
On December 11, 2025, medications were found in the Alleged Victim’s (AV) room. The facility conducted a thorough cleaning and search of the room that same day. Despite this, additional medications, equivalent to two days’ worth, were discovered again in AV’s room on December 16, 2025. Based on facility documentation and interviews, AV's room had been fully searched on December 11, it was determined the medications found on December 16 came from doses that were to be administered to AV between December 12 and December 16, 2025. Medication administration records show that Alleged Perpetrator 3 (AP3) was responsible for administering AV’s medications on December 13, and 14, 2025. AP3 did not watch AV swallow his/her medications. Between December 13, 2025, to December 14, 2025, AV experienced pain and discomfort as a result of not taking his/her medications as prescribed. AP3 failed to follow proper medication administration procedures by not watching AV swallow his/her medication, resulting in AV experiencing unreasonable discomfort. AP3's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.