- Date
- 10/8/2025
- Report number
- CALMS - 00096732
- 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 interview and record review, conducted during a site visit on October 10, 2025, the facility’s failure to ensure adequate professional oversight of the medication and treatment administration system was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to:
Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:
411-054-0055(1)(f-h): Systems: Medication and Treatment Orders; and
411-054-0055(2): Systems: Medication Administration
**Refer to allegations LCU00094743 and LCU00094748.
The facility failed to follow their own medication administration systems and did not document follow-though efforts to determine why the medication was unavailable nor was there oversight of the MAR by Staff 2 or Staff 3. Additionally, Staff 2 scheduled an emergency MT training on 09/04/25, however, Staff 5 and Staff 6, did not attend training and they continued to administer medications to the residents. Staff 5 and Staff 6 did not receive the emergency MT training until after the site visit on October 8, 2025. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.