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 ensure physician orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 1 of 2 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 2 moved into the memory care community in 03/2025 with diagnoses including dementia and anxiety. Review of the record indicated the resident had a physician’s order dated 06/16/26 for quetiapine fumarate oral tablet 25 mg, one tablet (25 mg) by mouth every day for agitation or restlessness. Resident 2’s 07/01/26 to 07/27/26 MAR was reviewed and indicated the resident was receiving one-half tablet (12.5 mg) daily, and not the prescribed one tablet. Staff 4 (LPN) stated in an interview on 07/28/26 at 1:30 pm that she was not sure how that occurred, noting the order had been through the facility’s triple check process. The need to ensure medications and treatments were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RCC) on 07/29/26 at 3:00 pm. They acknowledged the findings.

Resident #2 1.Upon identification of the deficient practice C0303, the RCC immediately reviewed the residents physician orders and medication records. Any discrepancies were corrected immediately. The family, and hospice were notified of discrepancy. An incident report was filled out and the resident was placed on alert. 2. MA's will receive re-education on physician order transcription, medication administration and requirements for carring out all medication and treatment orders exactly as prescribed. A 100% audit of all resident medication and treatment orders will be completed to verify that all phyician orders have been accurately transcribed and are being administered as prescribed. Any discrepancies identified during the audit will be corrected immediately, the PCP and family/Resident will be notified. An incident report will be filled out and resident will be placed on alert. A three check verification process will be completed for all new,changed and discontinued medication and treatment orders. First check is done by the MA and order is sent to the pharmacy to be trascribed into the EMAR.Second check is done by the RCC and third check will be completed by the nurse. 3. Medication pass observations will be conducted on a quarterly basis to verify compliance with physician orders and community policy. Re-edication will be done on a monthly basis. The RCC will complete weekly audits of medication and treatment orders. Orders will be processed by MA on shift/daily basis. 4. MA, RCC and nurse will be resposible to see that corrections are completed and monitored. Audit findings will be reviewed with the nurse and ED. Any identified concerns will be corrected immediately through education, coaching and when indicated disciplinary action.

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 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 C 303.

refer to plan of correction for 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: