Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the unannounced complaint investigation conducted 04/26/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.

Based on interview, and record review, it has been confirmed that the facility failed to carry out medication orders as prescribed. Findings include:

On 04/26/23, Compliance Specialist (CS) reviewed the facilities Incident Self Report dated 02/23/23 which revealed that Resident #1 (R1) was administered incorrect medications.  

The facility immediately notified the facility Registered Nurse, family, and PCP. R1 was placed on alert and monitored for 24 hours, and it was determined that R1 had no negative effects from the medication error.  

The above information was shared with Staff #1.

Facility Plan of Correction: The med-aide that administered the wrong medications to the wrong resident was immediately removed from the med room and stripped of duties.