Violation Details: 00453290-AP-405431

Records Request Print
Date
1/21/2026
Report number
00453290-AP-405431
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)(a) and (b)
411-054-0030(1)(f)
411-054-0036(2)(g)
411-054-0055(1(a) and (f)
Findings
The Alleged Victim (AV) resides in the Respondent’s facility and relies on facility staff to ensure that AV’s basic care, safety, and supervision needs are met. AV experiences pain in AV’s back and lower extremities and has scheduled medication for pain management. AV’s service plan reflects that AV requires moderate assistance with medication and that facility staff are responsible for administering both scheduled and PRN medications. However, the facility failed to maintain a safe medication administration system and did not ensure AV’s pain medications were available as prescribed. As a result, AV experienced pain and remained in AV’s room because ambulation caused significant discomfort. On or about January 23 and 24, 2026, AV missed scheduled pain medication due to the medication being unavailable. The Respondent failed to provide a safe medication administration system and did not ensure medications were available for administration as prescribed. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(A)(i).
Sanction
ALFCP26-00283 $250.00 fine assessed