Violation Details: 00453510-AP-405593

Records Request Print
Date
12/30/2025
Report number
00453510-AP-405593
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility for their care, including medication management. According to an investigation, from December 27, 2025, to December 30, 2025, AV missed multiple doses of pain medication, as it was unavailable. AV experienced pain and withdrawal symptoms. The facility failed to provide a safe medication administration system, which is a violation is neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00262 $500.00 fine assessed