Print Violation: CALMS - 00084752

Provider Information

Stephanie Gardens Residential Care

19751 SE STARK ST
Portland, OR 97233

Date: 1/1/2025
Report number: CALMS - 00084752
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(f)
Findings: Based on interview and record review, conducted during a site visit on 07/09/25, the facility’s failure to carry out medication and treatment 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 12/01/24 – 01/31/25 MAR’s and signed physician orders dated 12/26/24 indicated the following: An order for Cephalexin 500mg was reviewed: take one capsule by mouth four times daily for seven days for UTI; · Two doses of Cephalexin were recorded as given on 12/26/24, the start date; · One dose was given on 01/02/25, the end date; and · 27 of the 28-dose course of antibiotics were marked as administered. In an interview on 07/09/25, Staff 1 stated s/he had alerted hospice to the single missed dose, and the reason the last dose was not given was due to how the order had been entered into the system with an end date and time that was before the last dose was scheduled to be administered. The facility failed to carry out medication orders as prescribed is a violation of Oregon Administrative Rules.