Print Violation: 00374495-AP-324856

Provider Information

Mt. Bachelor Memory Care

20225 POWERS ROAD
Bend, OR 97702

Date: 12/18/2024
Report number: 00374495-AP-324856
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0055(1)(a)(f) and (2)
Findings: The Alleged Victim (AV) has severe cognitive deficits and relies on the facility to administer his/her medications. According to an investigation, on or about December 18, 2024, and December 19, 2024, the Alleged Perpetrator 2 (AP2) failed to administer medication as ordered when he/she marked AV's medication administration record (MAR) as Rivastigmine having been administered when AP2 had not administered the medication. The Rivastigmine medication was counted on December 20, 2024, and showed the medication had not been administered as ordered. This exposed AV to potential risk of serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.