Print Violation: 00425391-AP-376941

Provider Information

Footsteps at Tanasbourne

1950 NE 102ND AVENUE
Hillsboro, OR 97006

Date: 9/7/2025
Report number: 00425391-AP-376941
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide inservice
Result: Substantiated
Rule(s) Violated: 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)(b)
Findings: Alleged Perpetrator #2 (AP2) works at the facility as a caregiver, according to training records. There is no indication that AP2 was trained as a medication technician. On or about September 7, 2025, Alleged Perpetrator #2 (AP2) administered medications to the Alleged Victim (AV), however, AP2 had already administered AV's medications earlier. The medication was administered to AV accidentally, as AV was not sitting in his/her assigned seat, and the resident the medications were intended for looked similar to AV. AV was sent to the hospital and diagnosed with overdose of medication, causing altered mental status, low blood pressure and non-communicative and sleepy. AP2's actions were found to be inconclusive after investigation. Respondent failed to ensure staff were properly trained to carry out resident services for passing medication. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction: RCFCP26-00609 $250.00 fine assessed