Print Violation: 00414514-AP-365762

Provider Information

Santiam Gardens Residential Care

1625 CENTER ST NE
Salem, OR 97301

Date: 6/26/2025
Report number: 00414514-AP-365762
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: In July 2025, the facility experienced a breakdown in its medication management system, which directly affected an Alleged Victim (AV) under its care. Based on facility documentation and staff interviews, the facility failed to maintain a safe and accurate medication administration system. As a result, the Alleged Victim (AV) was administered a discontinued narcotic medication in addition to a newly prescribed narcotic medication which AV exhibited symptoms consistent with a drug overdose. AV experienced increased sedation that may have been a result of AV's medication not being administered as order. The facility’s failure to administer medications as ordered caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care, which constitutes abuse.
Sanction: RCFCP25-01138 $1500.00 fine assessed