- Date
- 12/30/2025
- Report number
- CALMS - 00119369
- 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 04/22/26-04/24/26, the facility failed to provide a safe medication administration system for Resident 1. Findings include but are not limited to: Resident 1 was admitted to the assisted living facility 05/2021. A review of the facility’s incident report dated 12/18/25, indicated Resident 1 reported s/he felt constipated and was unable to urinate. Resident 1 requested to be seen in the emergency room.
The following documents were reviewed for Resident 1:
- Service plan dated 10/30/25, indicated staff assistance for extensive and complex medication management. Staff were to administer both prescribed and PRN medications;
- Hospital discharge instructions dated 12/18/25, Resident 1 was given a new laxative “Senna” prescription;
- Medication administration record (MAR) for the month of 12/2025 indicated staff administered Resident 1’s Senna medication twice daily 12/18/25-12/31/25; and Physician order dated 12/18/25.
In an interview on 04/22/26, Witness 1 stated:
- On 12/30/25, Resident 1 showed Witness 1 where s/he had been stockpiling their Senna medications because Resident 1 didn’t feel s/he needed them;
- S/He saw approximately 15 medication cups in Resident 1’s room and each cup contained Senna medication; and
- S/He was concerned because Resident 1 had been to the emergency room on 12/18/25 for symptoms of constipation and was prescribed the Senna to alleviate potential issues; and
- Witness 1 reported the incident to Staff 1.
In an interview on 04/24/26, Staff 1 stated:
- S/He acknowledged Witness 1 reported Resident 1 was stockpiling medications and Staff 1 saw the medications in Resident 1’s room; and
- On 01/09/2026, med techs were re-trained on medication administration policy and procedures and were reminded they needed to watch residents ingest their medications prior to leaving the room.
The facility failure to ensure medication and treatment orders must be carried out as prescribed for Resident 1 is a violation of Oregon Administrative Rules.