OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 4 of 4 sampled residents (#s 3, 6, 7, and 8) whose MARs and controlled substance disposition logs were reviewed. Findings include, but are not limited to: 1. Resident 6 moved into the facility in 07/2024 with a diagnosis of multiple sclerosis. Resident 6 had a signed physician order for oxycodone 5-325 mg as needed for pain. Resident 6's controlled substance disposition log and MAR dated 05/01/26 to 05/19/26 were reviewed. The following was identified: There were 14 instances staff documented in the controlled substance disposition log as removing a tablet of oxycodone from locked storage; however, documentation on the MAR indicated it was administered six times. This was a discrepancy of eight tablets. Discrepancies between the MAR and the narcotic log were reviewed on 05/20/26 at 2:30 pm with Staff 1 (Campus Administrator) who stated she would investigate these occurrences. The need for the controlled substance disposition log to be accurate and for the disposition log and the MAR to match was discussed with Staff 1, Staff 2 (RN), Staff 3 (Wellness Coordinator), and Staff 4 (Wellness Services Coordinator) on 05/21/26 at 9:30 am. They acknowledged the findings. 2. Resident 7 moved into the facility in 02/2025 with a diagnosis of chronic pain. Resident 7 had a signed physician order for tramadol 50 mg as needed for pain or headaches. Resident 7's controlled substance disposition log and MAR dated 05/01/26 to 05/19/26 were reviewed. The following was identified: There were 24 instances staff documented in the controlled substance disposition log as removing a tablet of tramadol from locked storage; however, documentation on the MAR indicated it was only administered 22 times. This was a discrepancy of two tablets. Discrepancies between the MAR and the narcotic log were reviewed on 05/20/26 at 2:30 pm with Staff 1 (Campus Administrator) who stated she would investigate these occurrences. The need for the controlled substance disposition log to be accurate and for the disposition log and the MAR to match was discussed with Staff 1, Staff 2 (RN), Staff 3 (Wellness Coordinator), and Staff 4 (Wellness Services Coordinator) on 05/21/26 at 9:30 am. They acknowledged the findings. 3. Resident 8 moved into the facility in 03/2025 with diagnoses of migraines and lumbar stenosis (narrowing of the spine). Resident 8 had a signed physician order for oxycodone 10 mg as needed for pain. Resident 8’s controlled substance disposition log and MAR dated 05/01/26 to 05/19/26 were reviewed. The following was identified: There were 32 instances staff documented in the controlled Substance disposition log as removing a tablet of oxycodone from locked storage; however, documentation on the MAR indicated it was only administered 29 times. This was a discrepancy of three tablets. Discrepancies between the MAR and the narcotic log were reviewed on 05/20/26 at 2:30 pm with Staff 1 (Campus Administrator) who stated she would investigate these occurrences. The need for the controlled substance disposition log to be accurate and for the disposition log and the MAR to match was discussed with Staff 1, Staff 2 (RN), Staff 3 (Wellness Coordinator), and Staff 4 (Wellness Services Coordinator) on 05/21/26 at 9:30 am. They acknowledged the findings. 4. Resident 3 moved into the facility in 10/2019 with diagnoses including fibromyalgia (widespread body pain). Resident 3 had a signed physician order to receive 2 mg of hydromorphone every six hours as needed for pain. Resident 3's 05/01/26 to 05/17/26 controlled Substance disposition log and MAR were reviewed. The following deficiencies were identified: Staff documented in the controlled substance disposition log as having removed a tablet of hydromorphone from locked storage on ten occasions; however, documentation on the MAR indicated the medication was administered five times. This was a discrepancy of five tablets. Discrepancies between the MAR and the narcotic log were reviewed on 05/19/26 at 12:35 pm with Staff 1 (Campus Administrator) and Staff 2 (RN) who stated they would investigate these occurrences. The need to have a system in place for accurately tracking controlled substances administered by the facility was discussed with Staff 1, Staff 2, Staff 3 (Wellness Coordinator), and Staff 4 (Wellness Services Coordinator) on 05/21/26 at 10:29 am. They acknowledged the findings.

1.) Resident 6 was placed on alert monitoring for signs of unmanaged pain, increased pain, notification was sent to the PCP and family was notified. The resident was interviewed to ensure he/she was receiving pain medications when requested. An incident report was completed with full investigation and reported to Adult Protective Services. The Med Tech recevied coaching and counseling and received training on safe medication administration and Controlled Substance Policy and Procedure. Resident 7 was placed on alert monitoring for signs of unmanaged pain, increased pain, notification was sent to the PCP and family was notified. The resident was interviewed to ensure he/she was receiving pain medications upon request. An incident report was completed with full investigation and reported to Adult Protective Services. The Med Tech recevied coaching and counseling and training on safe medication administration and Controlled Substance Policy and Procedure. Resident 8 was placed on alert monitoring for signs of unmanaged pain, increased pain, notificaiton was sent to the PCP and family was notified. The resident was interviewed to ensure he/she was receiving pain medications when requested. An incident report was completed with full investigation and reported to Adult Protective Services. The Med Tech recevied coaching and counseling and training on safe medication administration and Controlled Substance Policy and Procedure. Resident 3 was placed on alert monitoring for signs of unmanaged pain, increased pain, notificaiton was sent to the PCP and family was notified. The resident was interviewed to ensure he/she was receiving pain medications when requested. An incident report was completed with full investigation and reported to Adult Protective Services. The Med Tech recevied coaching and counseling and training on safe medication administration and Controlled Substance Policy and Procedure. A full audit of all narcotic records is completed ensuring counts are accurate and documentation is accurately completed without further discrepencies. 2.) All Med Tech Training with full review of safe medication administration and Controlled Substance Policy and Procedure. Weekly audit of narcotic records to include the narcotic log and MAR will be conducted for 8 weeks and then returned to monthly as Policy requires. 3.) The area needing correction will be evaluated weekly. 4.) It is the responsibility of the Administrator and Wellness Services Coordinator to see that the corrections are completed and monitored.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: