Violation Details: 00481917-AP-434491

Records Request Print
Date
6/8/2026
Report number
00481917-AP-434491
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)(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 administration of medications. According to an investigation, in November 2025, AV went without their medication for approximately two days due to the order having no refills. On or about June 8, 2026, the facility was out of AV’s medication and requested a refill and again, the order had no refills. AV went without medication for at least 2 days, causing AV anxiety. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00300 $375.00 fine assessed