Print Violation: CALMS - 00098109

Provider Information

Powell Valley Assisted Living Community

4001 SE 182ND AVE
Gresham, OR 97030

Date: 8/23/2025
Report number: CALMS - 00098109
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: 411-054-0055(1)(f)
Findings: Based on interview and record review, conducted during a site visit on 01/13/26, the facility’s failure to ensure medication orders were carried out as prescribed was substantiated for 1 of 1 sampled resident (# 1). Findings include but are not limited to: In an interview on 01/13/26, Staff 2 stated on the evening of 08/23/25 she had been contacted by the training med tech on shift who told her a med tech trainee had administered a dose of morphine to the wrong resident. A review of facility Controlled Medication Discrepancy Report dated 08/23/25 indicated Resident 1 received a dose of morphine that was intended for another resident. A review of Resident 1’s signed physician orders dated 07/29/25 indicated the resident did not have an active order for morphine. A review of Resident 1’s temporary service plan dated 08/23/25 indicated resident was placed on alert following an incident where Resident 1 received another resident’s medication. Staff to monitor and take resident vitals on each shift. The Licensing Complaint Unit (LCU) determined the facility failed to carry out medication orders as prescribed which is a violation of Oregon Administrative Rules.