OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure medication and diet orders were carried out as prescribed, for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the MCC in 01/2025, with diagnoses including dementia, cerebral infarction, and hypertension. Resident 1’s MAR, dated 01/01/26 through 02/09/26, and physician orders, dated 01/05/26, included the following: * Morphine sulfate oral solution 20 mg/ml, 0.25 ml by mouth every 2 hours as needed for pain, shortness of breath. The physician order indicated Tylenol should be used first for pain; and * Acetaminophen 325 mg tab, 2 tablets (650 mg) by mouth every 4 hours as needed for pain or fever over 101, with instructions to use first for pain and if ineffective after one hour to administer prn morphine. The resident’s MAR showed 40 administrations of PRN morphine, without the acetaminophen (Tylenol) being administered first, as ordered. In an interview on 02/11/26 at 11:15 am, Staff 5 (MT/CG) showed the surveyor electronic records of the PRN morphine administrations and stated they were given for “serious chronic pain.” 2. Resident 2 was admitted to the MCC in 06/2025, with diagnoses including dementia, anxiety, and chronic obstructive pulmonary disease (COPD). Review of Resident 2’s physician orders, dated 01/05/26, and service plan, dated 11/30/25, revealed the following: * There was a physician order for “Regular diet, mechanical soft texture”; and * The service plan included instructions for pureed diet and nectar thick liquids, and indicated the resident choked easily. Observations made from 02/09/26 through 02/12/26, showed Resident 2 eating multiple meals and snacks of regular diet (no puree or mechanical soft texture) and no thickened liquids. In separate interviews on 02/11/26, Staff 5 (MT/CG), Staff 6 (MT/CG), and Staff 10 (CG) each stated Resident 2 was receiving a regular diet, with no altered textures. On 02/12/26 at 10:35 am, the need to ensure all medication and diet orders were carried out as prescribed was discussed with Staff 1 (ED). She acknowledged the findings.

1) All EMAR's will be reviewed by the Executive Director and RN to ensure proper parameters are in place for pain medication or any medication given to treat the same diagnosis or condition. Resident diets will reflect in EMAR as well as careplan correctly. 2) All med staff have been retrained on medication orders and paramaters before administering medications. Diets have been updated in care plans to reflect provider orders. 3) Weekly monitoring will be done for any new and changed orders, and quarterly by a Pharmacist Consultant. Quarterly care plan reviews will be double check to ensure diets are accuarte in care plan as they are listed in EMAR. 4) The Executive Director and RN will be responsible to be sure the correction is being monitored and completed.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C303.

Refer to C0303

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: