Violation Details: 00460269-AP-412535

Records Request Print
Date
2/20/2026
Report number
00460269-AP-412535
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
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) lived at Respondent's facility. The facility failed to maintain a safe medication administration system, resulting in the Alleged Victim (AV) receiving narcotic medications that did not match current orders. Facility documentation and interviews show that staff used an outdated Medication Administration Record (MAR), leading to AV receiving multiple incorrect dosages of narcotic pain medication. These medication administration errors caused AV unreasonable discomfort and resulted in hospitalization. The facility’s failure to administer medications as ordered placed AV at risk of harm and constitutes abuse by neglect under OAR 411-020-0002(1)(b)(A)(ii).
Sanction
ALFCP26-00236 $500.00 fine assessed