Print Violation: 00423045-AP-374507

Provider Information

River Terrace Memory Care

950 SOUTH END RD
Oregon City, OR 97045

Date: 8/24/2025
Report number: 00423045-AP-374507
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 August 24, 2025, the Alleged Perpetrator 2 (AP2) gave the AV a nighttime dose of 75 mg of medication for restless leg syndrome instead of the 25 mg that was prescribed for the morning dose. According to documentation, AV experienced increased leg pain following the medication error. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.