Print Violation: 00444364-AP-396354

Provider Information

Brookdale Salem

1355 BOONE RD SE
Salem, OR 97302

Date: 12/8/2025
Report number: 00444364-AP-396354
Type: Licensing Violation
Level: 0 - Not substantiated or inconclusive
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)
Findings: According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to the Alleged Victim (AV) by administering a medication that had been discontinued. On or about December 08, 2025, AP2 administered opioid medication to the AV. After the administration of the medications, the AP2 noticed the medication was discontinued in September. The AP2 did not follow protocol to notify appropriate parties of the medication error. The AP2’s failure to provide a safe medication placed the resident at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. the facility’s failure to oversee the medication administration system is a violation of Oregon Administrative Rules.