Print Violation: 00342935-AP-293550

Provider Information

River Terrace Memory Care

950 SOUTH END RD
Oregon City, OR 97045

Date: 1/8/2025
Report number: 00342935-AP-293550
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)
External site: 411-054-0055(1)(f)
Findings: The Alleged Victim (AV) relies on the facility for care and is care planned to have medication administration done by the facility. On or about January 8, 2025, the Alleged Perpetrator 2 (AP2) was observed giving AV 0.5 ml dose of an antiseizure medication instead of the prescribed dose of 5.0 ml. According to an investigation, AP2 indicated they had always given that dose and were not sure how many times the lower dose was given. It is estimated that AP2 potentially gave AV the lower dose approximately 16 times between December 4, 2024 and January 8, 2025, placing AV at risk for harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.