Violation Details: 00446817-AP-398839

Records Request Print
Date
12/23/2025
Report number
00446817-AP-398839
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)
External site: 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) receives his/her medication from facility staff. On or about December 23, 2025, Alleged Perpetrator #2 (AP2) was passing medications and gave AV narcotic medication which belonged to another resident. AV was allergic to the other resident's medication. AV suffered discomfort and dizziness from receiving the incorrect medication. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.