Violation Details: 00451274-AP-403586

Records Request Print
Date
1/14/2026
Report number
00451274-AP-403586
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(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 their care, including medication management. According to an investigation, on or about January 14, 2026, Alleged Perpetrator 2 (AP2) administered two doses of AV's anxiety medication, instead of one dose of anxiety medication, and a one dose of pain medication. AV went to the ER due to low oxygen saturation and blood pressure. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility failed to administer medication as ordered, which is a violation of Oregon Administrative Rules.