Print Violation: 00416838-AP-368102

Provider Information

Santiam Gardens Residential Care

1625 CENTER ST NE
Salem, OR 97301

Date: 7/28/2025
Report number: 00416838-AP-368102
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: Based on witness statements, investigator observations, and documentary evidence collected during Adult Protective Services (APS) Investigation #00416838, the APS Investigator determined that on or about July 28, 2025, the facility failed to provide a safe Medication Administration System for the Alleged Victim (AV). As a result of this failure, AV received a double dose of an antipsychotic medication, which caused AV to become lethargic and drowsy. AV was then transported to the Emergency Department for evaluation of antipsychotic medication toxicity. The facility's failure to provide a safe medication administration caused AV unnecessary and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction: RCFCP25-01242 $1013.00 fine assessed