Print Violation: 00414226-AP-394818

Provider Information

Mt. Bachelor Assisted Living

20215 POWERS ROAD
Bend, OR 97702

Date: 6/30/2025
Report number: 00414226-AP-394818
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)(e) and (f)
Findings: The Alleged Victim (AV) relies on the facility to administer his/her medications. According to an investigation, on or about July 6, 2025, AV did not receive anxiety medication as ordered. AV did not receive ordered medication on July 6, 2025, and July 12, 2025, resulting in AV experiencing increased anxiety. AP2 had marked the MAR as administered, but the narcotics log and medication count did not match. AP2's actions resulted in unreasonable discomfort for AV, are considered neglect and constitutes abuse. Medication audits had not been completed so the error was not identified. The facility failed to provide a safe medication system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP26-00120 $500.00 fine assessed