- Date
- 2/12/2026
- Report number
- 00470979-AP-423320
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On or about February 12, 2026, Alleged Victim was evaluated by his/her Primary Care Provider (PCP) for ongoing behavioral concerns. AV's PCP issued new medication orders, including a cross-taper from AV’s previous behavioral medication to a new behavioral medication and initiation of an anxiety medication. These orders were faxed to the facility. Facility documentation and interviews indicate the medication orders were not implemented in a timely manner. AP2 directed staff to withhold the prescribed medications due to disagreeing with the medication changes, despite not being licensed to override the PCP’s orders. As a result, the new behavioral medication was not started as ordered, and the anxiety medication was held without provider authorization until February 18, 2026. During this period, AV’s behaviors escalated, including a resident-to-resident aggression incident on February 14, 2026. Some improvement in symptoms was noted only after the delayed initiation of the anxiety medication. AV later experienced a fall requiring hospital transfer, followed by additional medication changes, and subsequently experienced a significant decline resulting in hospice placement. During the investigation, AV’s PCP stated it was their clinical opinion that the medication error and delay in implementing the ordered medications may have contributed to AV’s significant decline. AP2's actions caused AV unreasonable and unnecessary pain, discomfort, and harm which is considered neglect of care and constitutes abuse. AP2 also has a prior history related to this matter in which a Stipulated Final Order and Settlement Agreement was executed in Investigation 00299625-AP-253036. Both the February 12, 2026, incident and Investigation 00299625-AP-253036 demonstrate that AP2 has a pattern of repeatedly disregarding medication orders. The facility failed to ensure AP2 provided appropriate administrative oversight of the facility's medication administration system which is a violation of Oregon Administrative Rules.