Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00447590-AP-399607
Provider Information
The Bridge Assisted Living
201 SW BRIDGE STREET
Grants Pass, OR 97526
- Provider ID
- 70A266
- Administrator
- Alva Kilpatrick
- Phone
- (541) 956-2110
- ed@bridgeassistedliving.com
Violation Details
- Date
- 12/29/2025
- Report number
- 00447590-AP-399607
- 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
- Alleged Perpetrator 2 (AP2) failed to ensure that Alleged Victim's (AV) medications were administered as ordered, resulting in a significant medication administration error that caused physical harm to AV. On or about December 29, 2025, AV was given multiple medications that were not prescribed to AV, including antihypertensive medications and narcotics. As a result, AV experienced a critical drop in blood pressure, became lethargic, and was transported to the hospital for treatment. At the time of the incident, AP2 was training Witness 2 (W2) in medication administration. AP2 pre-popped medications intended for another resident, and those medications were subsequently administered to AV in error. Based on facility documentation and interviews, AP2 has a history of multiple documented medication errors. AP2's actions caused AV unnecessary physical harm and unreasonable discomfort, is considered neglect of care which constitutes abuse. The facility failed to provide adequate oversight of AP2, leading to AP2 improperly administering medication to AV, resulting in a hospital stay due to AV's blood pressure dropping and being lethargic. The facility's failure to provide a safe medication administration system for AV is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by 411-020-0002(1)(b)(A)(i).
- Sanction
- ALFCP26-00216 $375.00 fine assessed