Violation Details: 00466146-AP-418475

Records Request Print
Date
3/23/2026
Report number
00466146-AP-418475
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(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
From approximately, February 6, 2026, through March 21, 2026, the facility repeatedly failed to administer the Alleged Victim’s (AV) medication as ordered. As a resident of the facility, AV relies on the facility to correctly administer all prescribed medications. However, facility documentation and staff interviews show that staff did not follow AV’s prescribed medication regimen or Service Plan. The facility’s failure to provide appropriate oversight of its medication administration system to ensure AV’s medication orders were followed caused AV unnecessary discomfort, placing AV at risk of harm due to the prolonged 44-day failure. This failure constitutes abuse by neglect, as outlined in OAR as defined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
ALFCP26-00304 $188.00 fine assessed