Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/27/25.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified:

Abbreviations possibly used in this document:

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

HS:Hours of sleep

LPN:Licensed Practical Nurse

MT:            Medication Technician or Med Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

SP:Service plan

SPT:Service Planning Team

TAR:Treatment Administration Record

Based on interview and record review, conducted during a site visit on 02/27/25, the facility's failure to carry out medication orders for 1 of 1 sampled Resident (# 1) was substantiated. Findings include, but are not limited to:

Resident 1's service plan, dated 01/22/24, indicated Resident 1 was a total assist with medication, Med Tech to administer Resident 1's medications per physician's orders as noted on the MAR, and Staff to follow orders and administer all medications as directed.

Resident 1's MAR, dated 06/01/23 through 06/30/23, indicated Resident 1 had scheduled Olanzapine 2.5 mg tab (dementia related anxiety) with the instructions: "[one] tablet by mouth every evening after dinner," and Olanzapine 2.5 mg tab (agitation) with the instructions "[one] tablet by mouth every day as needed for severe agitation/distress/anxiety."

Resident 1's MARs, dated 07/01/23 through 11/30/23, indicated Olanzapine 2.5 mg tab was listed twice on the MAR under "as needed" medications.

Resident 1's MARs, dated 12/01/23 through 12/31/23, indicated Olanzapine 2.5 mg tab was listed three times on the MAR under "as needed" medications. The MAR indicated Olanzapine 2.5 mg tab was discontinued on 12/07/23.

Resident 1's narrative charting, dated 06/01/23 through 12/31/23, indicated on 06/29/23, Resident 1 received new orders for Olanzapine 2.5 mg.

Resident 1's physician orders, dated 05/19/23, indicated on 05/19/23, Resident 1 was prescribed Olanzapine 2.5 mg tablet with the instructions "Take [one] tablet by mouth daily as needed in addition to schedule dose for severe agitation/distress/anxiety that is not alleviated with nonpharmacologic strategies first," and Olanzapine 2.5 mg tablet with the instructions "Take [one] tablet by mouth every evening: give after dinner for dementia related anxiety/distress."

The facility self-report, dated 12/07/23, indicated Resident 1's scheduled Olanzapine order was entered incorrectly by the pharmacy and Resident 1 had not been administered his/her scheduled Olanzapine since 06/27/23.

Staff 1 (Director of Resident Services) stated Resident 1 did not receive the scheduled medication for some time. The pharmacy had incorrectly transcribed the medication on the MAR and entered it "as needed" and not scheduled.

It was determined the facility's failure to carry out medication orders for Resident 1 was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Residential Care Facility Administrator), and Staff 3 (Assistant Administrator).