Violation Details: 00458053-AP-410229

Records Request Print
Date
2/12/2026
Report number
00458053-AP-410229
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)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)(a) and (b)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff for medication administration. According to the AV’s Medication Administration Record (MAR), the AV was to receive 2 mg of the medication every Monday, Tuesday, Wednesday, Thursday, Saturday, and Sunday, and 1 mg every Friday. On or about February 12, 2026, Alleged Perpetrator 2 (AP2) administered 3 mg of the medication to AV instead of the prescribed 2 mg dose resulting in abnormal discoloration of AV's legs. AP2’s actions constitute neglect of care and meet the definition of abuse. The Respondent failed to ensure a safe medication administration system, which is a violation of the Oregon Administrative Rules.