Print Violation: CALMS - 00083427

Provider Information

Heron Pointe Senior Living

504 Gwinn Street East
Monmouth, OR 97361

Date: 9/11/2024
Report number: CALMS - 00083427
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to administer medication as ordered
Result: Substantiated
Rule(s) Violated: External site: 411-054-0055(1)(f)
Findings: Based on interview and record review, conducted during a site visit on 02/11/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's signed physician ordered, dated 08/29/24, revealed an order for: *"Hydrocodone/APAP 5-325 mg (norco) 1 Tab by mouth every 6 hours at 1000, 1600, 2200, and 0400". A review of Resident 1's MAR dated 09/01/24 through 09/30/24 revealed all four administrations were not completed on 09/11/24. An interview with Resident 1 confirmed s/he had not received his/her hydrocodone. The facility's failure to carry out medication orders as prescribed was substantiated. Verbal plan of correction: Facility will ensure medications are ordered seven days in advance whenever possible by adding a task to the MAR.