- Date
- 12/16/2025
- Report number
- 00446471-AP-398518
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about December 16, 2025, Alleged Perpetrator 2 (AP2) failed to notify appropriate staff of Alleged Victim’s (AV) request for PRN pain medication. As a result, AV experienced unnecessary and unrelieved pain for approximately two hours. AV is a resident of the facility and relies on staff to manage medications due to a diagnosed condition that causes intermittent pain. AP2 was a fully trained employee on duty at the time. AV requested assistance multiple times, including a request for a PRN pain reliever, and AP2 responded but did not communicate the request to Witness 2 (W2), the staff member responsible for administering medications. Approximately two hours later, AV spoke with Witness 4 (W4) and W4 learned that the medication request had not been passed on. Prescribed pain medication was available for AV during this period, but AV did not receive it due to AP2’s failure to communicate AV's request. AP2’s actions constitutes neglect of care, which is considered abuse. Additionally, the facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.