Violation Details: 00474858-AP-427232

Records Request Print
Date
5/5/2026
Report number
00474858-AP-427232
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility for their care, including medication management. According to an investigation, on or about, May 5, 2026, Alleged Perpetrator 2 (AP2) gave AV the wrong medication, resulting in AV's systolic blood pressure dropping and AV going to the hospital where they received fluids and monitoring. AP2’s action is considered neglect of care which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i). The facility failed to ensure the care plan was followed, which is a violation of Oregon Administrative Rules.