OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident injuries were promptly investigated to rule out abuse and/or neglect and reported to the local Department office if abuse could not reasonably be ruled out for 1 of 1 sampled residents (#1) who experienced injuries of unknown cause. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2024 with diagnoses including mild cognitive impairment, amnesia, and anxiety disorder. Resident 1 used a wheelchair for mobility and the medical record noted “For this resident emergency medical services (EMS) is called to assist when s/he falls to ensure safety.” Review of the record showed an incident report dated 02/04/26 which noted “Resident 1 reported s/he scraped his/her leg on the side of bed and fell to his/her knees. When asked, the resident reported they could not remember who helped them up but s/he must have had help because s/he is not sure they got up alone. Resident showing signs of confusion and unable to recall events in detail. Not witnessed.” A progress noted dated 02/05/26 titled “Fall” documented “resident is reporting that s/he is having a hard time bearing weight on right leg. Pain level 8 in right knee, lower outside of knee.” The investigation did not reasonably rule out abuse or neglect because the resident experienced an injury and was unable to say if they were alone or how the injury happened. The investigation dated 02/04/26 was not reviewed by the Administrator or reported to the local Department. 2. The LPN skin assessment dated 03/4/26 noted: “Groin area not assessed but per verbal update from Home Health Nurse on 03/4/26, there is what appears to be a skin tear on labia.” There was no documented explanation of the injury or how it happened. The next LPN skin assessment, dated 03/15/26, noted “groin area not assessed but per verbal update from Home Health Nurse, there is still redness and what appears to be a skin tear on labia.” The discovery of the unexplained wound was an injury of unknown cause. There was no documented evidence the wound was investigated to determine the cause, rule out abuse or neglect, and was not reported to the local Department office. 3. An ISP dated 03/15/26 documented the discovery of a “circular open area below right knee” and instructed staff to “monitor for signs of infection, drainage, hot to touch, odor or pain.” The unexplained wound constituted an injury of unknown cause. There was no documented evidence of an investigation or report to the Department office. The injuries were reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 15 (Assistant Regional Director of Operations), Staff 16 (Regional Executive Director), and Staff 3 (LPN) on 04/29/26 at 3:00 pm. Staff 15 initiated reporting of the 3 incidents to the local department office and confirmation of the report was received on 04/29/26. The need to ensure unexplained injuries were investigated and immediately reported to the local department office, if abuse or neglect could not be ruled out, was discussed with Staff 1, Staff 2, Staff 3, Staff 15, and Staff 16 at 3:30 pm. They acknowledged the findings.

1. Resident 1 injuries of unknown origin were reported to Adult Protective Services. 2. The Executive Director (ED), Licensed Nurses (LN), and Resident Care Coordinators (RCCs) have reviewed Oregon Assisted Living and Residential Care Abuse Reporting and Investigation Guide for Providers to ensure understanding of the community’s requirement for investigating injuries of unknown origin as well as other incidents to determine if abuse and neglect can be ruled out, and when indicated reporting immediately to the appropriate state agencies.Training on reporting requirements will be completed for all staff upon hire and annually thereafter as a refresher. 3. This system will be evaluated 5 days a week as part of daily standup process. During standup, Incident reports will be reviewed and when indicated, incidents will be immediately reported to APS. Additionally at standup, the 24-hour report will be reviewed, which includes a review of all progress notes written in the past 24 hours to identify any documented incidents or injuries that may not have had an incident report completed. On Mondays, the 72-hour report will be reviewed to include documentation from the weekend. 4. The Executive Director will be responsible for maintaining this system.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

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 treatment orders were carried out as prescribed for 2 of 4 sampled residents (#1 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 08/2022 with diagnoses including esophagitis and consequently was diagnosed with Barrett esophagus (damaged esophagus) in 06/2023. Review of Resident 4's physician orders and MARs from 03/01/26 through 04/27/26 revealed the following: a. Discharge orders dated 03/03/26 instructed providing a diet texture “soft and bite sized. Please provide naturally-pureed solids (e.g. mashed potatoes, apple sauce, yogurt, pudding) with each meal for comfort.” During observations on 04/29/26 and 04/30/26, Resident 4 was noted to be served regular textured food ordered from the standard menu, and naturally pureed solids were not offered. During interviews with Staff 11 (Cook) on 04/28/26 at 3:44 pm and Staff 17 (Culinary Director) on 04/30/26 at 9:10 am, both confirmed Resident 4 was not listed on the facility’s Resident Dietary Communication form, and no special diet instructions were implemented. Staff 2 (RN) notified the kitchen’s Person In Charge during sharing of findings and confirmed the prescribed diet was put in place. No negative outcome for Resident 4 was reported or observed, and facility update the diet texture information. b. Physician orders, dated 03/03/26, included the following: “Metoprolol succinate (for blood pressure) take 0.5 tablets by mouth every morning; hold if SBP [systolic blood pressure] < 100 or heart rate < 60; Please recheck BP [blood pressure] and heart rate at noon (during second med pass).” There was no documented evidence resident’s blood pressure and heart rate were checked at noon starting on 03/03/26. c. Physician orders, dated 04/25/26, stated, “please discontinue all previous meds and give [the new list].” The new list did not contain the previously given orders to administer empagliflozin 10mg (for heart failure), lisinopril 5mg (for high blood pressure), spironolactone 25mg (for heart failure), and torsemide 20mg (for edema). According to the MARs, staff continued to administer those medications on 04/26/26 and 04/27/26. d. Physician orders, dated 03/03/26, provided specific instructions for aspiration precautions including instructions to staff in case the resident “begins to cough, choke, sneeze, have wet voice or runny nose/eyes while eating...” Staff 12 (CG) was observed leaving a lunch tray in Resident 4’s room on 04/29/26 at 12:06 pm and locking the door upon exiting. During the interview on 04/30/26 at 11:05 am, Staff 12 confirmed caregivers “usually leave trays with resident and leave, then kitchen server comes to pick it up.” There was no evidence facility staff was monitoring Resident 4 when s/he dined in the room. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (LPN), Staff 15 (Assistant Regional Director of Operations), and Staff 16 (Regional Executive Director) on 04/30/26 at 3:42 pm. They acknowledged the findings.

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 treatment orders were carried out as prescribed for 2 of 4 sampled residents (#1 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 08/2022 with diagnoses including esophagitis and consequently was diagnosed with Barrett esophagus (damaged esophagus) in 06/2023. Review of Resident 4's physician orders and MARs from 03/01/26 through 04/27/26 revealed the following: a. Discharge orders dated 03/03/26 instructed providing a diet texture “soft and bite sized. Please provide naturally-pureed solids (e.g. mashed potatoes, apple sauce, yogurt, pudding) with each meal for comfort.” During observations on 04/29/26 and 04/30/26, Resident 4 was noted to be served regular textured food ordered from the standard menu, and naturally pureed solids were not offered. During interviews with Staff 11 (Cook) on 04/28/26 at 3:44 pm and Staff 17 (Culinary Director) on 04/30/26 at 9:10 am, both confirmed Resident 4 was not listed on the facility’s Resident Dietary Communication form, and no special diet instructions were implemented. Staff 2 (RN) notified the kitchen’s Person In Charge during sharing of findings and confirmed the prescribed diet was put in place. No negative outcome for Resident 4 was reported or observed, and facility update the diet texture information. b. Physician orders, dated 03/03/26, included the following: “Metoprolol succinate (for blood pressure) take 0.5 tablets by mouth every morning; hold if SBP [systolic blood pressure] < 100 or heart rate < 60; Please recheck BP [blood pressure] and heart rate at noon (during second med pass).” There was no documented evidence resident’s blood pressure and heart rate were checked at noon starting on 03/03/26. c. Physician orders, dated 04/25/26, stated, “please discontinue all previous meds and give [the new list].” The new list did not contain the previously given orders to administer empagliflozin 10mg (for heart failure), lisinopril 5mg (for high blood pressure), spironolactone 25mg (for heart failure), and torsemide 20mg (for edema). According to the MARs, staff continued to administer those medications on 04/26/26 and 04/27/26. d. Physician orders, dated 03/03/26, provided specific instructions for aspiration precautions including instructions to staff in case the resident “begins to cough, choke, sneeze, have wet voice or runny nose/eyes while eating...” Staff 12 (CG) was observed leaving a lunch tray in Resident 4’s room on 04/29/26 at 12:06 pm and locking the door upon exiting. During the interview on 04/30/26 at 11:05 am, Staff 12 confirmed caregivers “usually leave trays with resident and leave, then kitchen server comes to pick it up.” There was no evidence facility staff was monitoring Resident 4 when s/he dined in the room. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (LPN), Staff 15 (Assistant Regional Director of Operations), and Staff 16 (Regional Executive Director) on 04/30/26 at 3:42 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2024 with diagnosis including mild cognitive impairment. The resident's 04/01/26 to 04/30/26 MARs and physician orders were reviewed, and the following was identified: a. There were blanks on the MAR for the following medications: * Fluticasone 50 MCG/ACT (for congestion); * Lidocaine ointment 5% (for pain); * Nystatin powder 100,000 unit/gram (for fungal rash); and * Diclofenac sodium topical (for pain). In interview on 04/30/26 at 11 am, Staff 3 (LPN) confirmed the medications were not given on 04/05/26 due to a staff error. b. There were no signed, written orders in the resident’s record for the following treatments on the MAR: * Dermoplast spray (for pain); and * Nystatin powder 100,000 unit/gram (for fungal infection). The need to ensure orders were carried out as prescribed and written signed physician or other legally recognized practitioner orders were documented in the resident's record was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 15 (Assistant Regional Director of Operations), Staff 16 (Regional Executive Director), and Staff 3 (LPN) on 04/30/26 at 3:00 pm. They acknowledged the findings.

Resident #4 • Upon identification, the RN immediately verified and implemented the physician ordered soft and bite sized diet with naturally pureed solids at each meal. The resident was added to the facility’s Resident Dietary Communication form, and dietary staff were notified. • Blood pressure and heart rate monitoring for metoprolol administration was immediately initiated and documented per physician order. • Medications discontinued by the provider on 04/25/26 (empagliflozin, lisinopril, spironolactone, torsemide) were immediately stopped once identified, and MARs were corrected. • Aspiration precautions were reviewed, and staff were re instructed that Resident #4 requires monitoring during meals when eating in their room. Tray delivery without supervision was discontinued. Resident #1 • LN reviewed the MAR and identified missed medication doses and documentation errors. MARs were corrected to reflect accurate documentation. • Medication and treatment orders have been reconciled to ensure there is a signed physician order for all medications and treatments being administered. 2. A training has been scheduled with the entire clinical team to review the triple check process for all new orders as well as the requirement to have signed physician orders and the filing process. Training will also include the need for ISPs to be printed for all order changes and if the order change is related to diet orders, a copy must be given to the kitchen to update their records as well. Weekly MAR audits will be completed by the RCC to identify any missing documentation as well as to ensure parameters are being followed. Additional training will be provided to Med Aides when concerns are identified. 3. This system will be reviewed weekly through MAR audits and parameter audits as well as monthly as part of the CQI process which includes a review of all weekly audits as well as a reconciliation of diet orders. Physician orders will also be reconciled quarterly for all residents to ensure all medications and treatments have a signed order. 4. The Executive Director will be responsible for maintaining this system.

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 411-054-0055 (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 interview and record review, it was determined the facility failed to notify the prescriber when a resident refused to consent to orders for 1 of 4 sampled residents (#2) who had documented medication and/or treatment refusals. Findings include, but are not limited to: 1. Resident 2 moved into the community in 11/2024 with diagnoses including gastroesophageal reflux disease and a history of right humerus and left femur fractures. Resident 2’s MARS dated 04/01/26-04/28/26 and physician’s orders dated 03/12/26 were reviewed and revealed Resident 2 refused to consent to the following orders: Bupropion, clopidogrel, omeprazole, polyethylene glycol, trazodone, rosuvastatin: one occasion; Buspirone, oxycodone: two occasions; Calcium carbonate-cholecalciferol: three occasions; Liquid protein supplement: 17 occasions; and Morphine sulfate: four occasions. During an interview on 04/30/26 at 1:05 pm with Staff 3 (LPN), she stated the prescriber was to be faxed and a progress note made each time a resident refused his/her medication. There was no documented evidence the facility consistently notified the prescriber each time the resident refused to consent to the prescriber’s orders. The need to ensure the prescriber was notified of the resident’s refusal to consent to orders was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3, Staff 15 (Assistant Regional Director of Operations) and Staff 16 (Regional ED) on 04/30/26 at approximately 4:15 pm. They acknowledged the findings.

1. Physician for resident #2 was faxed a copy of all refusals for past 30 days. 2. To prevent recurrance, all Medication Aides will be re-educated on the regulatory requirement to notify providers with all medication or treatment refusals, unless we have an order in place stating the provider does not want to be notified. A list has been printed of providers who do or do not want to be notified has been printed and placed in the med room for quick reference. This list will be updated at least monthly. The 24-hour report will be reviewed at standup to identify any refusals and verify necessary notifications were completed. RCC will do a weekly audit of refusals to verify compliance. 3. This system will be evaluated weekly with refusal audits as well as monthly as part of our Continuous Quality Improvement (CQI) process which includes a review of the weekly audit results. 4. The Executive Director will be responsible for maintaining this system.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to maintain an accurate MAR, provide instructions and resident specific parameters for PRN medications for 2 of 4 sampled residents (#s1 and 2) whose MARS were reviewed. Findings include, but are not limited to: Resident 2 moved into the community in 11/2024 with diagnoses including gastroesophageal reflux disease and a history of right humerus and left femur fractures. Resident 2’s MARS dated 04/01/26-04/28/26 were reviewed. Resident 2 had three PRN medications for pain and lacked instructions to guide unlicensed staff as to which medication to administer for the resident’s complaints of pain: *Acetaminophen 325mg, give two tablets by mouth every six hours as needed for pain or fever greater than 100F; *Morphine sulfate 100mg/5ml, give 0.5ml by mouth every hour as needed for pain or SOB (shortness of breath); and *Oxycodone HCl 5mg, give 0.5 tablet by mouth as needed two times daily as needed for pain. Oxycodone HCl was administered one time between 04/01/26-04/28/26. Resident 2 had two PRN medications for nausea and lacked instructions to guide unlicensed staff as to which medication to administer for the resident’s complaints of nausea: *Ondansetron 4mg, give one tablet by mouth every four hours as needed for nausea; and *Haloperidol lactate 2mg/ml, give 0.25ml by mouth every two hours as needed for anxiety, agitation, hallucinations, nausea, vomiting. Ondansetron was administered five times and Haloperidol was administered one time between 04/01/26-04/28/26. Resident 2 had a PRN order for Flonase (a nasal spray that treats allergy symptoms) that lacked specific instructions for staff as to when the medication should be administered. During an interview on 04/29/26 at 10:15 am with Staff 3 (LPN), she acknowledged the lack of specific instructions for the PRN use of Flonase and the sequential order of administration for pain and nausea medications. The need to ensure the MARs included instructions and resident-specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3, Staff 15 (Assistant Regional Director of Operations) and Staff 16 (Regional ED) on 04/30/26 at approximately 4:15 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2024 with diagnosis including mild cognitive impairment and chronic pain. The 02/12/26 service plan documented “Resident requires assistance with medication administration”. The resident’s 04/01/2026 through 04/30/26 MARs and physician orders were reviewed. The following was identified: 1. The resident had used two as-needed prescriptions for pain, one for acetaminophen and one for oxycodone. There were no parameters instructing staff when to use the narcotic pain medication. 2. The MAR instructions for Loperamide 2mg (for diarrhea) was incorrectly transcribed from the physician's order dated 04/19/26. The need to ensure there were accurate instructions and parameters in place for multiple PRN medications for the same purpose was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 15 (Assistant Regional Director of Operations), Staff 16 (Regional Executive Director), and Staff 3 (LPN) on 04/29/26 at 3:00 pm. They acknowledged the findings.

1. For Resident #1 and Resident #2, the registered nurse (RN) reviewed all current physician orders and Medication Administration Records (MARs). Orders with multiple PRN medications for the same indication for use were corrected give clear instructions for use. The incorrectly transcribed loperamide order was corrected. 2. A meeting has been scheduled with the clinical to review the triple check process in full to include the following: • Proper transcription orders • Required elements of PRN medication instructions • Clear instructions for the unlicensed med aides when multiple PRN medications exist for the same indication for use. 3. This system will be evaluated quarterly for all residents as part of the order reconciliation which includes LN review of all orders, including PRN directions and parameters. Orders will then be sent to the provider for signature. PRN parameters will also be reviewed monthly as part of our CQI process. 4. The Executive Director will be responsible for maintaining this system.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: