F0755

D

Failure to Stock Correct Route of Ordered Emergency Narcan

Tigard, Oregon Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to provide the correct route of administration for an ordered emergency opioid antidote medication. A resident who was re-admitted in 12/2025 with multiple sclerosis, diabetes, and opioid use had a physician’s order dated 11/2025 for naloxone HCL (Narcan) nasal liquid 4 mg/0.1 mL to be administered in both nostrils as needed for decreased responsiveness. During an observation of the facility’s emergency kit on 2/19/26 at 12:34 PM, surveyors identified that Narcan was stocked only in an intravenous (IV) form rather than the prescribed nasal route for this resident. On 2/20/26 at 2:46 PM, the Administrator acknowledged that the facility did not have the correct nasal route formulation of Narcan available for the resident.

This deficiency reflects the facility’s failure to obtain and maintain the ordered nasal formulation of naloxone in its emergency supply for a resident with an active PRN order for nasal Narcan for decreased responsiveness, as confirmed by observation of the emergency kit contents and staff acknowledgment.