Violation Details: 00463901-AP-416195

Records Request Print Provider Details
Date
3/6/2026
Report number
00463901-AP-416195
Type
Abuse: Neglect
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(b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility for their care, including medication management. According to an investigation, on or about March 5, 2026, AV was tested for a UTI and an antibiotic was ordered the next day. AV did not start their antibiotic medication until approximately March 11, 2026, as it could not be located, posing a risk of harm. AV was also seen to be “out of it” and “not aware” and noted to be in pain. The facility failed to provide a safe medication administration system and failed to ensure medication was administered as ordered, which is a violation of resident rights, is neglect of care which constitutes abuse.