Violation Details: 00466193-AP-418554

Records Request Print
Date
3/22/2026
Report number
00466193-AP-418554
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
On or about March 20, 2026, the Alleged Victim (AV) ran out of his/her medication. On or about March 26, 2026, staff advised that AV was out of medication. Between March 20, 2026, and March 26, 2026, AV's medication was not re-ordered and AV did not receive the medication during that time, which placed AV at risk for harm. Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) failed to notify staff that medication needed to be reordered. The facility failed to have a medication review process for missed medication in place to ensure residents received all medications timely and didn't run out of medication. AP2 and AP3's actions were determined to be inconclusive for abuse. Respondent failed to ensure resident medications were re-ordered timely. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
RCFCP26-00659 $250.00 fine assessed