Print Violation: 00402346-AP-353255

Provider Information

Bonaventure of Medford Memory Care

2530 EAST MCANDREWS ROAD
Medford, OR 97504

Date: 5/16/2025
Report number: 00402346-AP-353255
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)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: The Alleged Victim (AV) receives his/her medication from facility staff. On or about May 9, 2025, Alleged Perpetrator #2 (AP2) administered the incorrect insulin to AV, as the incorrect medication was obtained by AP2 from another pharmacy, and AP2 did not check to ensure the medication was the correct type for AV, which placed AV at risk for serious harm. On or about May 13 to May 15, 2025, AV missed three doses of insulin, due to orders not being placed in the system correctly. Alleged Perpetrator #3 (AP3) edited the original order for AV's insulin to 7:40 am, 8:00 am and 4:00 pm, resulting in AV's blood sugars not being checked or receiving his/her medication at lunch time for three days, causing AV to be hospitalized due to an adverse reaction and uncontrolled blood sugar levels. AP2 and AP3's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure a safe medication administration system is a violation of Oregon Administrative Rules.