Print Violation: 00409731-AP-360818

Provider Information

Mt. Bachelor Memory Care

20225 POWERS ROAD
Bend, OR 97702

Date: 6/5/2025
Report number: 00409731-AP-360818
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: 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) and (f), 411-054-0070(2)(a)
Findings: Alleged Victim (AV) relies on facility staff to administer medications. According to an investigation, on or about, June 20, 2025, it was discovered that the AV had not received prescribed daily Lithium from 6/5/2025 through 6/22/2025. The Alleged Perpetrator 2 (AP2) did not administer the medication to AV, but had marked the medication administration record (MAR) as administered. AP2's actions exposed AV to risk of serious harm, are considered neglect and constitutes abuse. Based on the investigation, it was determined that the facility did not provide a safe medication administration system and did not provide required training to AP2, which is a violation of resident rights, is neglect of care which constitutes abuse. The allegation that the Alleged Perpetrator 3 (AP3) neglected AV was investigated and determined to be inconclusive.
Sanction: RCFCP25-01307 $500.00 fine assessed