Print Violation: 00428432-AP-380118

Provider Information

Skylark Assisted Living

900 SKYLARK PLACE
Ashland, OR 97520

Date: 9/21/2025
Report number: 00428432-AP-380118
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious 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) relies on the facility to manage their medications, including insulin injections. The AV was prescribed long-acting insulin before bed and had an order for short-acting insulin that was on hold. According to an investigation, on or about September 21, 2025, the AV did not have enough long-acting insulin for their evening dose. Alleged Perpetrator 2 (AP2) did not follow proper procedure for medications and gave the AV their short acting-insulin. AP2 did not notify management of the medication error. The AV had a negative reaction and required hospitalization to address their blood sugars. AP2’s actions are a violation of resident rights, considered neglect, and constitute abuse. The facility failed to ensure a safe medication system by not ordering the AV's medications timely, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.
Sanction: ALFCP26-00004 $375.00 fine assessed