Print Violation: 00455086-AP-407209

Provider Information

Oak Lane Residential Care Facility

727 SW ROGUE RIVER AVENUE
Grants Pass, OR 97526

Date: 2/3/2026
Report number: 00455086-AP-407209
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: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: The facility failed to ensure that Alleged Victim (AV) received AV’s prescribed pain medication during two separate periods, resulting in AV experiencing significant and preventable pain, discomfort, and withdrawal symptoms. As a resident, AV relies on facility staff to appropriately order, manage, and administer all prescribed medications. During the facility-initiated pharmacy transition, the facility proceeded with the pharmacy change without a plan in place to ensure continued access to AV’s prescribed pain medication. Facility documentation and staff interviews indicate that AV did not receive his/her pain medication from approximately October 25, 2025, to October 31, 2025, and again from November 15, 2025, to November 18, 2025. The facility's failure to provide a safe medication administration system for AV caused AV continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00558 $1500.00 fine assessed