- Date
- 5/9/2026
- Report number
- 00475867-AP-428255
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On or about May 9, 2026, Alleged Perpetrator 2 (AP2), a facility employee, administered another resident’s pre-poured medications to Alleged Victim (AV). These medications included a muscle relaxant that AV is known to be allergic to. According to facility records and interviews, AP2 completed general orientation on or about January 13, 2026, and had completed all required Oregon Care Partners trainings before the incident. AP2 had previously made medication errors and had been retrained. At the time of the incident, AP2 was carrying multiple medication cups intended for different residents and gave AV the incorrect cup. As a result of receiving the wrong medications, AV required hospitalization and emergency inpatient dialysis to remove the muscle relaxant from their system. AP2 failed to administer AV's medication as ordered which caused AV unreasonable discomfort requiring hospitalization. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system to ensure AV's medications were administered as ordered which is a violation of Oregon Administrative Rules.