Print Inspection: CHOW009080

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by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.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 1 of 1 sampled resident (# 3) whose MARs and Controlled Substance Disposition Logs were reviewed for accuracy. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2023 with diagnoses including anxiety. The resident’s MAR, dated 01/01/26 through 01/26/26, and the Controlled Substance Disposition Log, dated 01/01/26 through 01/26/26, were reviewed. The following was identified: Resident 3’s MAR reflected staff to administer 5mg oxycodone, three times a day, as needed for pain. The Controlled Substance Disposition Log showed the resident received 5 mg oxycodone on 01/04/26, 01/14/26, and 01/26/26. There was no documented evidence on the resident’s MAR that the dispensed medication was administered to the resident. In an interview on 01/29/26 at 1:28 pm, Staff 3 (RN) and Staff 12 (Regional RN), confirmed discrepancies between the controlled substance disposition log and the MAR. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (General Manager), Staff 3, and Staff 4 (MCC Director) on 01/29/26 at 1:30 pm. They acknowledged the findings.

1. Resident 3's MARs were updated to reflect the administration of the controlled pain medication on 01/04/26, 01/14/26, and 01/26/26. 2. All med techs will receive additional training on the appropriate documentation of administering narcotics to include both documentation of administration in the MARs and the Controlled Substance Disposition logs. When the oncoming med tech performs a narcotic count with the leaving med tech at shift change, med techs will check to ensure they have signed out any applicable narcotics in MARs. The commnunity RN will then audit weekly to ensure appropriate documentation by auditing the Controlled Substance Disposition logs and ensuring all narcotics that have been signed out are also documented in the MAR as given as well. 3. This area of correction will need to be evaluated by the med tech at the end of their shift each day as described above and further evaluated by the community RN on a weekly basis to ensure compliance. 4. The RN will be responsible to ensure the corrections are completed and ensure compliance.

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:

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 keep an accurate MAR and ensure there were resident specific parameters and instructions for PRN medications for 3 of 4 sampled residents (#s 1, 2, and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 admitted to the facility in 11/2025 with diagnoses including edema, hypertension, atrial fibrillation, and depression and had a recent hip replacement surgery. The resident’s physician’s orders and MARs, dated 01/01/26 through 01/26/26, were reviewed. The following inaccuracies were noted: a. The following medications had no reason for use: * Amlodipine (to treat high blood pressure); * Calcium (supplement); * Furosemide (to remove excess fluid); * Losartan (to treat high blood pressure); * Mycophenolic (to prevent rejection of a transplant); * Prednisone (to reduce inflammation); * Simvastatin (to lower cholesterol); and * Trazodone (to treat major depressive disorder). b. Blanks were identified on 01/15/26 and 01/16/26 at the 9:00 pm administration for the following medications: * Calcium; * Mycophenolic; * Simvastatin; * Trazodone; and * Warfarin (an anticoagulant). During an interview with Staff 1 (General Manager) and Staff 3 (RN) on 01/29/26 at 12:55 pm, it was confirmed the resident received the medications on both days. The need to ensure the medication record contained a reason for use and initials of the person administering the medication was discussed with Staff 1, Staff 3, Staff 11 (Senior General Manager), and Staff 12 (Regional RN) on 01/28/26 at 2:52 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 04/2023 with diagnoses including acute kidney failure. Residents 2's MARs were reviewed from 01/01/26 through 01/26/26 and revealed the following: a. The following medications were missing initials of the person who administered the medications: * Acidophilus (probiotic) on 01/17/26; * Amlodipine (for blood pressure) on 01/10/26; * Amoxicillin (an antibiotic) on 01/10/26; * Cranberry (for acute kidney failure) on 01/17/26; * Methenam (for acute kidney failure) on 01/10/26, 01/15/26 and 01/17/26; * Metropolol (for blood pressure) 01/17/26; and * Vitamin C (for preventing urinary tract infection) on 01/17/26. b. The following medications lacked a reason for use: * Acidophilus (probiotic); * Amlodipine (for blood pressure); and * Vitamin D3 (supplement). A review of the MAR with Staff 3 (RN) on 01/28/26 at 11:40 am confirmed the above medications lacked a reason for use. The need to ensure the medication record contained a reason for use and initials of the person administering the medication was discussed with Staff 1 (General Manager), Staff 3, Staff 11 (Senior General Manager), and Staff 12 (Regional RN) on 01/28/26 at 1:58 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 05/2023 with diagnoses including hypertension and anxiety. Resident 3's 01/01/26 through 01/26/26 MAR and TAR were reviewed. The following was identified: * Multiple PRN pain medications, including oxycodone, Tylenol and Robaxin added did not have clear parameters to instruct unlicensed staff regarding when the medications should be administered, and which medication should be given first. Oxycodone was administered multiple times between 01/01/26 and 01/26/26; * Multiple PRN anxiety medications, including Ativan and Inderal, lacked clear parameters regarding when they should be administered, and which medication should be given first. Both PRN anxiety medications were not administered during the review period; * Staff were directed to perform wound care on sacral area. However, there were no clear instructions specifying the required wound care to be performed; * Multiple scheduled medications including Lipitor (for cholesterol), Levothyroxine (for thyroid hormone), Remeron (for depression), and oxycodone (for pain) had no reason for use; and * Staff were directed to apply Baza protect cream 12% to the resident’s skin. However, the specific treatment location and frequency were not indicated. In an interview on 01/29/26 at 1:28 pm, Staff 3 (RN) and Staff 12 (Regional RN) reported the facility’s health services department conducted weekly and monthly reviews of the MARs and the medication system. In addition, the facility received quarterly pharmacy reviews. However, there was a period when the facility did not have an RN. Staff 3 started working at the facility towards the end of 12/2025 and was still in the training process. The need for resident-specific parameters and instructions for PRN medications and for all medications to have a documented reason for use were discussed with Staff 1 (General Manager), Staff 3, and Staff 4 (MCC Director) on 01/29/26 at 1:30 pm. They acknowledged the findings.

1. Resident 1, 2, and 3's MARs were updated to include resident specific parameters and instructions for PRN medications. Resident 1's orders were reviewed and updated to ensure each medication order included the reason for use. Resident 1's MARs were updated with the applicable initials to verify that the applicable meds were given on 01/15/26 and 01/16/26 to resolve blanks. For Resident 2, MARs were updated to include any missing medication administration documentation after staff verification. Resident 2 and 3's orders were reviewed and updated to ensure each medication order included the reason for use. Resident 3's instructions for pain medications were updated to be clear. Resident 3's psychotropic medication's indicators for use were updated to be clear and different. Resident 3's orders were reviewed to ensure all medication orders were transcribed appropriately to include location and frequency on the applicable cream order. 2. All resident MAR's will be audited to ensure that all orders have been transcribed to ensure accuracy. Audit will also include that all medications, including pain, psychotropic, bowel medications, include appropriate and clear instructions, parameters, and indicators for use. Training will occur with Administrator, med techs, and nurses to inform and explain this regulation as well as the importance. Training to include to notify nursing, and/or fax the doctor for clarification when and if orders are not clear. System and training implemented of a triple check system of all medication orders to ensure that orders have been transcribed and clear instructions and/or parameters have been given. 3. This will be evaluated with any order changes through the triple check system among med techs and nurses. This will also be evaluated through our pharmacy audit and by our community RN at the time of the quarterly evaluations. 4. The Administrator and community RN will be responsible to ensure completion and ongoing monitoring.

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:

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility. Findings include, but are not limited to: The facility had a system that alarmed staff to their handheld electronic devices which displayed a text message stating which door had opened. An audit of the system was conducted with Staff 1 (General Manager) and Staff 2 (Maintenance Director) 01/29/26 at 11:50 am. Staff 1 showed her handheld device to this surveyor. The device reflected that the electronic alarms alerted staff when exit doors were used, except for doors #s 5 and 9. Staff 1 and Staff 2 acknowledged these findings. It was identified that exit doors, #s 5 and 9, failed to have a working alarm or other acceptable system to alert staff when residents left the building. The need to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed on 01/29/26 at 12:00 pm with Staff 1, Staff 3 (RN), and Staff 11 (Senior General Manager). They acknowledged the findings.

1. Exit doors #s 5 and 9 have now been equipped with a working alarm that is a part of our wireless nurse call system of which will alert staff members immediately to their handheld electric devices. 2. This alarm device has been added to the two missing doors so that this violation does not occur again. 3. All exit doors will be audited to ensure working alarms on a quarterly basis by the Maintenance Director to ensure compliance. Results will be reported to the Administrator to verify compliance. Any issues/concerns of the doors will be resolved/fixed timely. 4. The Maintenance Director and the Administrator will be responsible to ensure completion and ongoing monitoring.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: