- Date
- 7/7/2026
- Report number
- CALMS - 00121423
- 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 reviews conducted during a site visit on 07/28/26, the facility failed to ensure medications were carried out as prescribed and physician’s orders were followed was substantiated for 1 of 1 sampled residents (#1). Findings include but are not limited to the following:
On 07/28/26 following documents were reviewed for Resident 1 (R1):
Incident report #3660 dated 07/07/26 indicated Lorazepam 1mg on 07/07/26 @19:18 instead of Lorazepam 0.5mg. Note on 07/10/26 stated bubble cards for both dosages were in the narcotics drawer. Note indicated on 07/10/26 that staff would be re-educated on medication administration.
Progress notes effective date 07/07/26 9:48, for Medication error. Resident was given Lorazepam 1mg instead of 0.5mg as per order. Resident was found sleeping in another resident's bed.
MAR indicated a D/C date of 07/02/26 for Lorazepman 1mg.
Physician’s Orders dated 07/02/26 with a received date of 07/03/26 indicated an order to start Lorazepam oral tablet 0.5mg 2 times daily.
Interview with Staff 2 (Med Tech) stated she/he caught an error when doing the medication count on 07/08/26 for day shift and the bubble pack for 1mg Lorazepam should have had a sticker with bold red letters “Directions change refer to chart”. Staff 2 stated R1 changed from 0.5mg am and 1mg in pm to 0.5mg twice per day on 07/03/26.
Staff 2 showed Compliance Specialist an example of the red sticker that would indicate a change of medication.
The facility’s failure to ensure R1’s medication and physician’s orders were carried out as prescribed is a violation of Oregon Administrative Rules.