- Date
- 8/19/2025
- Report number
- CALMS - 00094707
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Based on observations, interviews, and record review conducted during a site visit on October 23, 2025, it was determined that the facility failed to implement a safe and effective medication administration system for 1 of 1 sampled resident (Resident #1). Specifically, the facility did not ensure that prescribed medication and treatment orders were carried out as directed by the healthcare provider. This failure resulted in unreasonable discomfort to the resident and constitutes a violation of resident rights. The substantiated findings meet the definitions of neglect of care and abuse under applicable regulatory standards. Although the resident did not experience a negative outcome, the facility’s failure to carry out prescribed medication and treatment orders constitutes noncompliance with Oregon Administrative Rule.