Print Violation: 00456123-AP-408282

Provider Information

Newberry Estates Memory Care Community

1025 NE PURCELL BLVD
Bend, OR 97701

Date: 2/6/2026
Report number: 00456123-AP-408282
Type: Licensing Violation
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV), a resident under the facility’s care, was given another resident’s medications by Alleged Perpetrator 2 (AP2) on or about February 6, 2026. Shortly after receiving the incorrect medication, AV became unresponsive and experienced bradycardia, requiring transport to the hospital for treatment. Facility documentation and interviews show that AP2 was properly trained and had met competency requirements for medication administration prior to this incident involving AV. AP2’s medication error caused AV unreasonable discomfort and adverse side effects, is considered neglect of care and constitutes abuse. The facility failed to maintain a safe medication administration system to ensure AV received medications as ordered which is a violation of Oregon Administrative Rules.