Violation Details: 00479343-AP-431809

Records Request Print
Date
5/26/2026
Report number
00479343-AP-431809
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)(a) and (b)
411-054-0027(1)(g)
411-054-0055(1)(f)
Findings
The Alleged Victim (AV) relied on the facility for care and medication administration. On or about May 26, 2026, the Alleged Perpetrator 2 (AP2) administered AV a medication that belonged to another resident, resulting in AV being transferred to the hospital due to abnormally low blood pressure and shock. AV was at high risk of organ failure, deterioration, and/or death and AV required critical care management in a critical care unit. AP2's actions are considered neglect of care and constitute abuse as defined by OAR 411-020-0002(1)(b)(A). The facility failed to ensure medications were administered as ordered which is a violation of Oregon Administrative Rules.