Print Violation: 00460411-AP-412693

Provider Information

Avamere Living at Newberg

730 FOOTHILLS DRIVE
Newberg, OR 97132

Date: 2/25/2026
Report number: 00460411-AP-412693
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0055(1)(a) and (f)
Findings: On or about February 25, 2026, at approximately 8:30 PM, Alleged Perpetrator 2 (AP2) administered Alleged Victim's (AV) medication twice instead of once, resulting in AV receiving an extra dose. Based on facility documentation and interviews, AP2 had been trained and deemed competent to administer medications, including the requirement to perform a triple-check prior to each administration. As a result of AP2's medication administration of AV's medication, resulted in AV experiencing unreasonable discomfort which included confusion, drowsiness, and lethargy. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.