- Date
- 7/6/2026
- Report number
- CALMS - 00119377
- 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 an investigation on 07/20/26, the facility’s failure to ensure medication and treatment orders must be carried out as prescribed was substantiated for 1 of 1 (#1) sampled resident. Findings include, but are not limited to:
The following documents were reviewed:
• Resident 1’s Service Plan dated 06/05/26;
• Resident 1’s Hospital After Visit Summary dated 07/07/26;
• Resident 1’s Progress Notes dated 07/01/26 – 07/20/26; and
• Resident 1’s MAR dated 07/01/26 – 07/31/26.
A review of Resident 1’s progress notes indicated s/he was given the wrong dose of h/h pain medication. On one occasion Resident 1 was given h/h morning dose of pain medication instead of the PRN dose as requested. On the second occasion Resident 1 was given h/h bedtime dose of pain medication instead of the PRN dose as requested. The facility’s failure to ensure medication and treatment orders are carried out as prescribed is a violation of Oregon Administrative Rules.