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by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.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 ensure a system for tracking controlled substances for 1 of 1 sampled resident (#1) who was prescribed narcotic medication for pain. Findings include, but are not limited to: Resident 1 was admitted to the facility in 05/2026 with diagnoses including chronic pain and was identified in the acuity interview on 08/05/26 as receiving PRN morphine. The resident’s current signed prescriber orders, 08/01/26 to 08/05/26 MAR, and corresponding pages from the controlled substance disposition log were reviewed. The following was identified: Resident 1 had signed prescriber orders for morphine 20 mg/ml solution, take 0.25 ml by mouth or under the tongue every 15 minutes PRN for pain or shortness of breath. Staff documented the following: * 08/01/26 – the controlled substance disposition log indicated the morphine was administered nine times, while the MAR had only six entries; * 08/02/26 – the controlled substance disposition log indicated the morphine was administered eight times, while the MAR had only two entries; * 08/04/26 – the controlled substance disposition log indicated the morphine was administered five times, while the MAR had only four entries. The 9:06 pm entry on the MAR had no corresponding entry on the controlled substance disposition log; and * 08/02/26 – the two entries for 2:51 pm and 11:35 pm on the controlled substance disposition log had no corresponding entries on the MAR, and the 10:39 am entry on the MAR had no corresponding entry on the controlled substance disposition log. The discrepancies were reviewed, and the need to ensure a system to track controlled substances was discussed with Staff 1 (Health Services Director) at 11:14 am on 08/06/26. He acknowledged the findings, and no further information was provided.

Immediately upon identification of the deficiency, the facility reviewed its system for tracking controlled substances and disposal documentation. All controlled medication records, narcotic count sheets, medication administration records (MARs), and medication disposal logs were audited for accuracy and completeness. Any identified discrepancies were corrected and documented. Completion Date: 8/7/2026 2. How Other Residents Will Be Protected The facility conducted a facility-wide review of all controlled substances to ensure: • Accurate shift-to-shift controlled substance counts. • Proper documentation of administration and inventory. • Proper documentation of disposal for unused, outdated, and discontinued medications. • Compliance with facility policy and Oregon administrative rules. Any additional discrepancies identified during the audit were corrected immediately. Completion Date: 8/7/2026 3. Systemic Changes Implemented To ensure ongoing compliance with OAR 411-054-0055(1)(e), the facility has: • Revised and reinforced its controlled substance tracking system. • Verified that the controlled substance tracking process has been reviewed and approved by the Registered Nurse. • Re-educated all medication aides, licensed nurses, and applicable staff on: • Controlled substance count procedures. • Documentation requirements for controlled medications. • Procedures for reporting and investigating discrepancies. • Requirements for disposal of unused, outdated, and discontinued medications. • Implemented routine oversight by the Administrator and RN designee to verify ongoing compliance. Completion Date: 8/7/2026 4. Monitoring Process The RN and/or Administrator will: • Conduct weekly audits of controlled substance count records and disposal logs for four weeks. • Conduct monthly audits for the following two months. • Review audit findings with staff and provide corrective coaching as needed. • Maintain audit records through the facility's Quality Assurance process. • Immediately investigate and resolve any discrepancies identified during monitoring. 5. Person Responsible Administrator: Qasim Abdul Registered Nurse: Samir Abdul, RN 6. Date Compliance Achieved

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: