Print Inspection: CHOW013613

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 admitted to the facility in 07/2026 with diagnoses including moderate vascular dementia and Alzheimer’s disease. Observations were made and interviews with the resident and facility staff were conducted. Resident 1’s service plan, dated 08/05/26, and multiple interim service plans were reviewed. The resident’s service plan was not reflective of his/her current needs and lacked clear direction to staff in the following areas: * Mobility devices used; * Transfer devices used; * Palliative care; * Resident 1’s ability to evacuate during an emergency; and * The resident’s preference to keep his/her apartment door closed during the night and for staff to wait until they were given permission to enter the apartment after knocking. On 08/10/26 at 2:01 pm, Resident 1’s apartment door was open with a sign directing visitors to knock first. The resident stated that staff knock and open the door, which s/he felt was not “appropriate” while s/he was in bed at night. Resident 1 explained that s/he opened the apartment door after rising and dressing in the morning. The resident shut the door before s/he got ready for bed. An electric wheelchair was also observed, and Resident 1 confirmed s/he was “still practicing how to use it.” The service plan did not address the resident’s door preferences or the use of an electric wheelchair. On 08/11/26 at 11:27 am, Staff 7 (MT) and Staff 11 (CG) confirmed Resident 1 no longer used a walker to transfer and had not seen him/her use the walker since shortly after admission. The need to ensure service plans reflected residents' current needs, provided clear direction to staff, and were implemented was reviewed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 1:02 pm. They acknowledged the findings. 2. Resident 3 admitted to the facility in 09/2025 with diagnoses including insulin dependent diabetes and dry eye syndrome. The resident returned to the facility on 08/06/26 from skilled nursing care relating to a fall that resulted in a fractured pelvis. Observations were made and interviews with Resident 3 and facility staff were conducted. The resident’s service plan, dated 08/06/26, and multiple interim service plans were reviewed. The resident’s service plan was not reflective of his/her current needs and lacked clear direction to staff in the following areas: * Low vision in his/her left eye; * How the resident transferred and when a second person was needed; * Staff monitoring of blood glucose levels; * Assistance needed with grooming and hygiene; * Increased incontinence at night; * Ability to put laundry away; and * Safety checks. The need to ensure service plans reflected residents' current needs, provided clear direction to staff, and were implemented was reviewed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 3:15 pm. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 09/2023 with diagnoses including hemiplegia affecting dominant side, Type 2 diabetes mellitus and pain in spine. The resident’s 06/14/26 service plan, progress notes and interim service plans from 05/10/26 to 08/10/26, were reviewed. Observations of the resident were obtained, and the resident and care staff were interviewed. The resident’s current service plan lacked information and instructions regarding: * The CPAP machine; * The resident’s preferred laundry detergent; * The arm brace; and * The cat. During an interview with Resident 4 on 08/11/26 at 1:45 pm, a continuous positive airway pressure (CPAP) machine was observed in the resident’s room. The resident also kept a cat. The resident confirmed s/he used the CPAP at night while sleeping and stated that s/he managed the use and maintenance of the device independently. The resident explained that a peer from down the hallway helped him/her maintain the cat’s litter box. In an interview on 08/12/26 at 2:10 pm, Staff 13 (CG) reported the resident used a special laundry detergent due to chronic skin issues and staff assisted the resident each evening before bed with donning an arm brace. Resident 4’s service plan was reviewed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director), and Staff 3 (RCC) on 08/12/26 at 2:25 pm. They acknowledged the information lacking from the service plan.

1. What actions will be taken to correct the rule violation for each example/resident? Resident 1: By 10/11/26, the RCC/designee and facility nurse will complete a comprehensive reassessment and revise the service plan to accurately address current mobility and transfer devices, palliative-care involvement, emergency-evacuation ability and assistance, and the resident's privacy preference that the apartment door remain closed at night and staff knock and wait for permission before entering, except during an emergency or when immediate access is required for safety. The revised plan will specify what staff must do, when, how, and how often, and will be communicated to direct-care staff on all shifts. Resident 3: By 10/11/26, the RCC/designee and facility nurse will reassess and revise the service plan to address left-eye low vision, transfer method and the circumstances requiring a second staff member, blood-glucose monitoring responsibilities and frequency, grooming and hygiene assistance, increased nighttime incontinence, laundry assistance, and the type and frequency of safety checks. Staff on all shifts will receive the updated directions. Resident 4: By 10/11/26, the RCC/designee and facility nurse will revise the service plan to address the resident's independent use and maintenance of the CPAP, staff assistance with the arm brace, preferred laundry detergent, and care/safety arrangements related to the resident's cat, including who is responsible for litter-box maintenance. The revised directions will be communicated to care staff. For each cited resident, the corrected service plan will be dated, offered to the resident or legal representative, medicaid case manager and will be reflected in ABST as applicable, and reviewed with assigned staff before the staff member next provides the affected service. 2. How will the system be corrected so this violation will not happen again? By 10/11/26, the RCC, facility nurse, and Administrator will review all current resident service plans against the most recent evaluation, interim service plans, provider orders, incident/change-of-condition documentation, and observed care needs. Identified omissions or conflicts will be corrected promptly, communicated to staff, offered to the resident or representative, and updated in ABST care elements when applicable. The RCC and facility nurse will educate care and medication staff on following the current service plan and promptly reporting any discrepancy or change. Staff competency will be verified through teach-back and review of resident-specific assignments. Any inaccurate plan identified in an audit will be corrected before the end of the next business day and communicated to all affected shifts. 3. How often will the area needing correction be evaluated? The RCC or designee will audit 100% of newly created service plans and review for accuracy to make sure all required components are in place. All existing residents will be reviewed in 30 days after move in, every 90 days and when a significant change of condition occurs. 4. Who will be responsible to see that the corrections are completed/monitored? The RCC/facility nurse and Executive Director.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition, ensure the staff instructions or interventions were resident-specific, document weekly progress until the condition resolved and monitor the resident consistent with his or her evaluated needs and service plan for 3 of 4 sampled residents (#s 1, 2 and 4) who experienced changes of condition that required monitoring. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 09/2023 with diagnoses including hemiplegia affecting dominant side, Type 2 diabetes mellitus and pain in spine. Progress notes, interim service plans (ISPs) and incident reports from 05/10/26 to 08/10/26 were reviewed. The following was identified: a. When the facility identified a resident change of condition, it placed the resident on “Alert Charting” and developed a written ISP that gave staff instructions for how to intervene and monitor the resident. * On 05/28/26, the resident’s dosage of oxycodone (for pain) was decreased. The ISP directed staff to monitor for “sweating, body chills, nausea, irritability and etc.” * On 06/25/26, the resident was involved in a heated verbal conflict with a peer. The ISP directed staff to monitor for “increase in behaviors.” * On 07/09/26, the resident was administered a PRN dose of oxycodone without having a valid order to do so. The ISP directed staff to monitor for “increase in pain, body aches, muscle/joint aches.” In an interview on 08/12/26 at 2:25 pm, Staff 1 (Administrator) and Staff 2 (Regional Health and Wellness Director) acknowledged the instructions for staff on the ISPs lacked resident-specific information or instructions for staff. Staff 1 and Staff 2 stated the 05/28/26 ISP should have also directed staff to monitor for increased complaints of pain; the 06/25/26 ISP should have also informed staff with whom Resident 4 had the conflict and directed staff to supervise the residents if they interacted with each other; and the 07/09/26 ISP should have directed staff to monitor for common side effects such as drowsiness, dizziness, nausea, vomiting and headache. b. Between 05/28/26 and 08/10/26, the record indicated Resident 4 experienced six changes of condition: an increase in agitated behavior, a resident altercation and four medication dosage changes. Though the facility documented monitoring of each of these conditions, there was no documented evidence the facility determined the conditions had resolved. c. Resident 4’s record indicated s/he was being treated for two wounds/skin issues. An outside service provider was providing wound care to a lower leg ulcer three times per week, and the facility was providing cleaning and administration of protective creams to bilateral sores on the resident’s upper thighs twice daily. The last progress note regarding the status of the lower leg wound was dated 06/05/26. There was no documentation in the resident’s record regarding the status of the upper thigh wounds. In an interview on 08/12/26 at 11:43 am, Staff 2 reported she could not find any other documentation in Resident 4’s record regarding the status of the wounds. She stated the facility should have been monitoring the status of the wounds weekly. The need to ensure the facility developed resident-specific instructions or interventions for staff, documented monitoring until the condition was resolved and monitored the resident consistent with his or her evaluated needs was reviewed with Staff 1, Staff 2 and Staff 3 (RCC) on 08/12/26 at 2:25 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2020 with diagnoses including dementia and hypothyroidism. The resident’s 05/08/26 to 08/10/26 clinical record was reviewed, and the following was identified: * 07/13/26 – Staff documented the resident had bruising on the right forehead, right side of neck, right forearm and right leg below the knee due to a recent fall. There was no documented evidence the bruises were monitored, with weekly progress noted through resolution; and * 07/14/26 – The resident’s order for levothyroxine (for thyroid function) was discontinued by hospice. There was no documented evidence staff were informed of the change and instructed to monitor for symptoms related to the discontinued medication, with weekly progress noted through resolution. The need to ensure resident-specific instructions to staff and weekly monitoring to resolution occurred for resident short-term changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (Regional Health and Wellness Director) at 12:19 pm on 08/12/26. They acknowledged the findings, and no further information was provided. 3. Resident 1 was admitted to the facility in 07/2026 with diagnoses including asymptomatic human immunodeficiency virus and hypertension. The resident’s 07/03/26 to 08/10/26 clinical record was reviewed, and the following was identified: a. There was no documented evidence Resident 1 was monitored with weekly progress noted through resolution for the following changes of condition: * 07/03/26: Moved into the facility; * 07/19/26: Addition of scheduled acetaminophen (used for pain); * 07/30/26: Missed a scheduled dose of acetaminophen; and * 08/02/26: Scheduled acetaminophen changed from three times a day to twice a day. b. On 07/07/26, the resident's palliative care provider reduced the dose of scheduled Eliquis (used for stroke prevention). There was no documented evidence the facility determined and documented what actions or interventions were needed, communicated the actions or interventions to staff on each shift, and monitored the condition with weekly progress noted through resolution. c. There was no documented evidence the facility determined and documented what actions or interventions were needed, communicated the actions or interventions to staff on each shift, and monitored the condition with weekly progress noted through resolution for the following dates related to missed medications: * 07/13/26: Systane ultra drops (used for cataracts); * 07/23/26: Abacavir (used for HIV-1 infection) and Tivicay (used to prevent HIV-1 from multiplying); and * 07/31/26: Carvedilol (used to lower blood pressure). The need to ensure the facility determined and documented actions or interventions were needed, communicated the actions or interventions to staff on each shift, and monitored the condition with weekly progress noted through resolution was reviewed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 1:02 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Resident 4: By 10/11/26, the facility nurse/RCC will review the six cited changes of condition and document current status or resolution, including the 05/28/26 oxycodone decrease, 06/25/26 resident conflict, 07/09/26 medication event, increased agitation, and subsequent medication changes. Resident-specific monitoring directions will address expected symptoms, pain, adverse medication effects, the persons/circumstances involved in the conflict, supervision needed during interactions, reporting thresholds, and when to notify the nurse/provider. The lower-leg ulcer and bilateral upper-thigh skin conditions will be assessed and documented; current treatment orders and outside-provider records will be obtained, and weekly status documentation will continue until each condition is resolved or incorporated into the ongoing service plan. Resident 2: By 10/11/26, the facility nurse/RCC will assess and document the current status or resolution of the bruising identified after the fall and the effect of discontinued levothyroxine, obtain provider/hospice direction as needed, establish resident-specific monitoring and notification parameters, and document weekly progress until resolution or incorporation into the ongoing service plan. Resident 1: By 10/11/26, the facility nurse/RCC will review and document the outcome of the move-in monitoring, scheduled acetaminophen addition/dose change, reduced Eliquis dose, missed acetaminophen, Systane, abacavir, Tivicay, and carvedilol doses. The provider/palliative-care team will be notified when clinically indicated, resident-specific monitoring and reporting directions will be documented, and weekly progress will continue until resolution or incorporation into the ongoing service plan. If any retrospective finding cannot be clinically reconstructed, that limitation will be documented and the resident's current condition will be assessed, with the provider notified as appropriate. 2. How will the system be corrected so this violation will not happen again? By 10/11/26, the facility will implement a change-of-condition workflow requiring the initiating staff member to notify the designated nurse/manager, document the condition, identify whether it is short-term or significant, establish resident-specific interventions and notification parameters, communicate instructions to every shift, and update the evaluation/service plan for a significant change. Each change-of-condition/alert record will include a start date, weekly clinical progress note, and explicit resolution date or transition into the ongoing service plan. Generic directions such as 'monitor behaviors' or 'monitor symptoms' will not be accepted without resident-specific signs, frequency, interventions, and escalation criteria. All care and medication staff will be educated on identifying, documenting, and escalating physical, emotional, and mental changes. A 24-hour reporting protocol and on-call contact will be available on every shift. The RCC/facility nurse will review the alert/change-of-condition list each business day and unresolved items at least weekly. 3. How often will the area needing correction be evaluated? The RCC or facility nurse will review the active alert/change-of-condition list each business day and document a weekly review of every open condition until resolution. Defects will be corrected promptly, with staff re-education and re-audit within seven days. 4. Who will be responsible to see that the corrections are completed/monitored? The facility nurse is responsible for clinical determination, resident-specific monitoring instructions, provider notification, and resolution. The RCC is responsible for shift communication, tracking, and record completion. The Administrator is responsible for staff training and audit oversight.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure outside service providers left written information in the facility that addressed the onsite services being provided, facility management or licensed nurse were notified of services provided by the outside provider to ensure that staff were informed of new interventions, and/or information obtained from residents’ visits to outside medical providers was included in the resident’s record with adjustments made to the resident’s services and service plan for 3 of 3 sampled residents (#s 2, 3, and 4) who received services from outside providers. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 07/2020 with diagnoses including dementia. Staff reported in the 08/10/26 acuity interview the resident had a recent hospital stay due to a fall and was discharged on hospice. The resident’s 05/08/26 to 08/10/26 clinical record was reviewed, and the following was identified: A hospital discharge summary dated 07/13/26 included signed prescriber orders to discontinue atorvastatin 40 mg tablet (for high cholesterol), one tablet by mouth every day and ferrous gluconate 324 mg tablet (iron supplement), one tablet by mouth every day. Review of the MAR showed staff continued to administer both medications through 08/09/26. In an interview at 3:42 pm on 08/11/26, Staff 6 (MT) confirmed the medications had not been discontinued as ordered. He stated MT staff were supposed to fax any new orders to the resident’s pharmacy and initial the order. Another MT would double check and initial to confirm the orders were sent, and finally, Staff 3 would review the orders and initial that they had been processed. He stated the process for any new orders from after visit summaries “should be the same;” however, he confirmed the after visit summary from the hospital discharge lacked initials showing they had been reviewed. The need to ensure the resident’s service plan was adjusted as applicable following a visit to an outside provider was discussed with Staff 1 (Administrator) and Staff 2 (Regional Health and Wellness Director) at 12:19 pm on 08/12/26. They acknowledged the findings, and no further information was provided. 2. Resident 4 was admitted to the facility in 09/2023 with diagnoses including hemiplegia affecting dominant side, Type 2 diabetes mellitus and pain in spine. Resident 4’s record indicated an outside service provider was providing wound care to a lower leg ulcer three times per week. In an interview on 08/11/26 at 1:45 pm, Resident 4 confirmed s/he either went out to the service provider clinic every Monday, Wednesday and Friday for wound care, or a nurse from the program came to the facility to provide the wound care. On 08/12/26 at 9:30 am, the surveyor met with Staff 1 (Administrator) and Staff 2 (Regional Health and Wellness Director) and requested documentation of the wound care visits and status of the wound. On 08/12/26 at 11:43 am, Staff 2 provided the surveyor with visit notes dated 07/29/26 and 08/05/26. She acknowledged the facility had not been obtaining records of the resident’s off-site visits to the outside provider clinic, nor had it ensured the provider left written information in the facility when wound care was provided on-site in the facility. The need to ensure the facility obtained information from the outside provider when the resident went out to the clinic and when the provider provided wound care on site was reviewed with Staff 1 (Administrator), Staff 2 and Staff 3 (RCC) on 08/12/26 at 2:25 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 09/2025 with diagnoses including aneurysm of vertebral artery and insulin dependent diabetes. Staff reported in the 08/10/26 acuity interview the resident had a recent hospital stay due to a fall that resulted in a pelvic fracture. The resident’s 05/08/26 to 08/10/26 clinical record was reviewed, and the following was identified: a. A hospital after visit summary dated 08/03/26 included signed physician’s orders for the following medications: * Sennosides (used for constipation); * Refresh tears directing staff to administer one drop, four times a day on the date of injection and the day after; * Vitamin D3 (used as a supplement); * Lovenox injection (for clot prevention) daily through 08/11/26; * Protonix, 20 mgs, one tablet daily until 08/17/26; * Miralax (used for constipation); * Melatonin (used for sleep); and * Dapagliflozin (used to lower blood sugar). There was no documented evidence the medications were transcribed to the resident’s MAR. On 08/12/26 at 11:25 am, the resident confirmed s/he had an appointment with the ophthalmologist for an eye injection on 08/14/26. b. In addition to the medications, the after visit summary specified that Resident 3 was "Toe touch weight bearing right lower extremity [for four] weeks." There was no documented evidence this was communicated to staff. On 08/11/26 at 1:45 pm, Staff 7 (MT) reported she was not aware of the resident's weight bearing status. The need to ensure the resident’s service plan was adjusted as applicable following a visit to an outside provider was discussed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 3:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Resident 2: The facility nurse/RCC will immediately reconcile the 07/13/26 hospital discharge orders with the current signed orders, MAR, pharmacy profile, hospice plan, and service plan. The prescriber/hospice and pharmacy will be contacted to verify current directions for atorvastatin and ferrous gluconate and to assess whether follow-up is needed because the medications continued after discontinuation orders. All resulting orders, notifications, and resident monitoring will be documented by 10/11/26. Resident 4: By 10/11/26, the facility will obtain available wound-clinic/home-health notes, current wound status, treatment orders, and reporting parameters for lower-leg wound visits. The facility will establish with the outside provider that written visit information must be left or transmitted after every on-site or off-site service. The facility nurse will review each report, update staff instructions and the service plan, and ensure supplemental care and weekly wound monitoring are documented. Resident 3: The facility nurse/RCC will reconcile the 08/03/26 after-visit summary with current prescriber orders, MAR/TAR, pharmacy records, and the service plan. Each listed medication will be verified, transcribed or discontinued only according to a valid order, and implemented as prescribed. The toe-touch weight-bearing restriction will be confirmed with the provider, entered into the service plan/task system with transfer and mobility directions, and communicated to staff on all shifts by 10/11/26. 2. How will the system be corrected so this violation will not happen again? A standardized return-from-appointment/hospital and outside-provider workflow will require staff to obtain written information, route it the same shift to the facility nurse/RCC, compare it with current orders and the MAR/TAR, send new orders to the pharmacy, update the service plan/task system, communicate changes to all shifts, and document completion using a two-person verification. For on-site providers, the facility will maintain a visit log and require a written note or secure electronic report after each service. For off-site visits, staff will send relevant resident information, request an after-visit summary, and track missing documentation until received. The facility nurse will review all health-related service-plan changes. 3. How often will the area needing correction be evaluated? The RCC/facility nurse will review the outside-provider and return-from-appointment notes each business day for incomplete follow-up. Missing information or unprocessed orders will be escalated the same day and corrected promptly. 4. Who will be responsible to see that the corrections are completed/monitored? The RCC coordinates receipt and routing of outside-provider records. The facility nurse reviews clinical information, reconciles orders, and updates health-related services. The Administrator monitors completion and audits.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. 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 carry out medication and treatment orders as prescribed and ensure written, signed physician orders were documented in the resident’s record for all medications and treatments that the facility was responsible to administer for 3 of 4 sampled residents (#s 1, 3 and 4) whose orders and MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 09/2023 with diagnoses including hemiplegia affecting dominant side, Type 2 diabetes mellitus and pain in spine. Review of the resident’s most recent signed orders list, dated 07/02/26, subsequent orders in the resident’s record and the 07/01/26 to 08/10/26 MARs indicated the following: a. Resident 4 was prescribed the following medications that included orders to hold the medications based on specific parameters: * Carvedilol (to treat high blood pressure) BID – hold if systolic blood pressure (SBP) is less than 110 or if heart rate is less than 50. * Losartan (to treat high blood pressure) once daily – hold if systolic blood pressure is less than 110. * Torsemide (to treat high blood pressure) once daily – hold if systolic blood pressure is less than 110. Between 07/01/26 and 08/10/26, the MAR indicated Resident 4’s SBP was less than 110 on nine occasions and his/her heart rate was below 50 on one additional occasion. On these occasions, the facility should have held the above medications per the orders. The MAR indicated the facility failed to hold the carvedilol on five of 10 occasions, and the losartan and torsemide on three of nine occasions. b. The facility did not have written, signed physician orders in the resident’s record for the following medications and treatments that were being administered: * Clotrim/betameth 1-0.05% cream apply topically to affected areas every day; * Clotrimazole 1% cream apply to rash in skin folds every day; * Zinc oxide 25% paste apply to rash in skin folds every day; and * A wound care treatment that was being administered by facility staff twice per day to the resident’s upper thighs. On 08/11/26 at 10:45 am, the surveyor met with Staff 3 (RCC) and requested orders for the above medications and treatment. On 08/12/26 at 12:43 pm, Staff 3 acknowledged the facility did not have those orders in the resident’s record and said she had requested written orders from the resident’s primary care physician. The orders and MAR were reviewed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 2:25 pm. They acknowledged the lack of orders and failure to hold the medications as ordered. 2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including hypertension and congestive heart failure. Review of the resident’s signed physician’s orders, dated 06/23/26, subsequent orders in the resident’s record and the 07/03/26 to 08/10/26 MARs indicated the following: a. The facility failed to follow prescriber orders relating to the following: On 06/23/26, the resident's physician ordered the facility to check vitals and weights weekly, which included the following parameters on when to notify her: * If the systolic blood pressure was below 100 or above 180 and if the diastolic blood pressure was below 50 or above 90; and * If the resident's weight was greater than 142 pounds. There was no documented evidence the physician was notified on the eight times the resident's blood pressures were outside the parameters. There was no documented evidence the physician was notified on 07/21/26 and 07/27/26 when Resident 1’s recorded weight was 142.2 pounds. In addition, there was no documented evidence the facility weighed the resident between 07/03/26 and 07/21/26. On 07/31/26, Resident 1’s palliative team directed staff to weigh Resident 1 daily and notify them of a three-pound weight gain in one day and of a five-pound weight gain in one week. There was no documented evidence the resident was weighed on 08/09/26. There was no documented evidence palliative care was notified on 08/05/26 of a 4.7 weight gain in one day. b. There was no written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the following medication and treatment the facility was responsible to administer: * Eliquis (used for stroke prevention); and * Systane ultra drops (used for cataracts). The need to ensure the facility carried out medication and treatment orders as prescribed and ensure written, signed physician orders were documented in the resident’s record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 1:02 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 09/2025 with diagnoses including aneurysm of vertebral artery and insulin dependent diabetes. Staff reported in the 08/10/26 acuity interview the resident had a recent hospital stay due to a fall that resulted in a pelvic fracture. Review of the resident’s signed physician’s orders, dated 08/03/26, and the 07/01/26 to 08/10/26 MARs indicated the following: a. Physician's orders were not carried out as prescribed for the following medications: * Acetaminophen (used to treat pain) 325 mgs: The MAR reflected administering two tablets, three times a day but the physician's order directed the facility to administer "three tablets" three times a day; and * Pantoprazole (used for acid reflux) 40 mgs: The MAR directed the facility to administer one tablet by mouth every day 30 minutes before a meal, but the physician's order directed staff to administer 20 mgs daily through 08/17/26. b. There were signed physician’s orders for the following medications: * Scheduled sennosides (used for constipation); * Refresh tears (used for dry eye); * Vitamin D3 (used as a supplement); * Lovenox injection (used for clot prevention) daily through 08/11/26; * Protonix, 20 mgs, one tablet daily until 08/17/26; * Scheduled Miralax (used for constipation); * Melatonin (used for sleep); and * Dapagliflozin (used to lower blood sugar). There was no documented evidence the medications and treatments had been carried out as prescribed, as they had not been transcribed to the MAR. c. Jardiance (used as an antidiabetic) was transcribed onto the resident’s MAR and staff were signing they had administered the medication. There was no current signed physician or other legally recognized practitioner order for the medication documented in Resident 3’s facility record. The need to ensure the facility carried out medication and treatment orders as prescribed and ensure written, signed physician orders were documented in the resident’s record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 3:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Resident 4: The facility nurse/RCC will complete an immediate order-to-MAR/TAR reconciliation. Carvedilol, losartan, and torsemide hold parameters will be verified, clearly displayed, and communicated to medication staff; the prescriber will be notified of cited doses not held and any follow-up obtained. Written signed orders will be obtained for clotrimazole/betamethasone cream, clotrimazole cream, zinc oxide paste, and the bilateral upper-thigh wound treatment before further facility administration, unless the prescriber discontinues or changes them. Current wound status and treatment response will be documented by 10/11/26. Resident 1: The facility nurse/RCC will reconcile the weekly/daily weight and vital-sign orders, ensure all frequencies and notification thresholds are accurately on the MAR/TAR task system, and notify the prescriber/palliative team of cited out-of-range blood pressures, weights, the missed 08/09/26 weight, and the 08/05/26 one-day weight increase, with clinical follow-up documented. Current written signed orders for Eliquis and Systane drops will be obtained and verified before continued facility administration by 10/11/26. Resident 3: The facility nurse/RCC will reconcile the 08/03/26 signed orders with the MAR and pharmacy profile. Acetaminophen and pantoprazole/Protonix directions will be clarified with the prescriber and corrected. Sennosides, Refresh tears, vitamin D3, Lovenox, Protonix, Miralax, melatonin, and dapagliflozin will be transcribed and carried out only as currently ordered. A current signed order for Jardiance will be obtained and verified, or the medication will be held/discontinued only under prescriber direction. The resident will be assessed and the prescriber notified of identified discrepancies as clinically indicated. 2. How will the system be corrected so this violation will not happen again? By 10/11/26, the facility nurse/RCC will complete a 100% reconciliation of current resident signed orders against the MAR/TAR, pharmacy profile, treatment sheets, outside-provider documents, and medication supply. Discrepancies will be clarified with the prescriber and corrected before administration whenever practicable; urgent safety concerns will be escalated immediately. Medication staff will be trained to stop and contact the nurse/RCC when an order is missing, unclear, conflicting, expired, or not present on the MAR/TAR. At every medication-cycle change and following every hospital/SNF return, the facility nurse will reconcile the signed order list, MAR/TAR, pharmacy profile, and medication supply. 3. How often will the area needing correction be evaluated? The facility nurse/RCC will review every new or changed medication/treatment order by the next business day. Any discrepancy will be addressed immediately and re-audited within seven days. Results will be reviewed quarterly. 4. Who will be responsible to see that the corrections are completed/monitored? The facility nurse is responsible for clinical reconciliation, prescriber communication, and review of health-related orders. The RCC is responsible for order tracking, MAR/TAR transcription workflow, and shift communication. The Administrator is accountable for completion and audit oversight.

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 (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 medication administration record (MAR) for all medications that were ordered by a legally recognized prescriber and were administered by the facility for 3 of 4 sampled residents (#s 1, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 09/2023 with diagnoses including hemiplegia affecting dominant side, Type 2 diabetes mellitus and pain in spine. Review of the resident’s 07/01/26 through 08/10/26 MAR indicated the following: a. Resident 4 was prescribed two PRN medications to treat pain: * Acetaminophen 500 mg tablets, two tablets TID for pain; and * Oxycodone 5 mg tablet, 0.5 tablet once per day as needed for acute or breakthrough pain. The MAR lacked resident-specific parameters and instructions to guide unlicensed staff as to which medication to administer and under what circumstances. b. On 08/05/26, the resident’s oxycodone order was changed to allow the resident to be administered the medication as needed three times daily at 7:00 am, 12:00 pm and 7:00 pm. In an interview on 08/12/26 at approximately 12:15 pm, Staff 3 (RCC) confirmed that between 08/06/26 and 08/10/26, the facility electronic MAR would not allow the MTs to document when they administered the 12:00 pm dose. The MTs documented in progress notes on 08/06/26 and 08/08/26 that the medication had been administered. However, there was no documented evidence the 12:00 pm dose of the medication had been administered on 08/07/26, 08/09/26 and 08/10/26. The need to ensure documentation on the MAR was accurate was reviewed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 on 08/12/26 at 2:25 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 07/2026 with diagnoses including hypertension and congestive heart failure. Review of the resident’s MARs, dated 07/03/26 through 08/10/26, indicated the following: a. The MAR lacked staff signatures relating to the administration of medications and treatments on 07/10/26: * Carvedilol (used to lower blood pressure); * Nitroglycerin patch (used to treat chest pain); * Pregabalin (used as an anticonvulsant); * Systane ultra drops (used for cataracts); and * Eliquis (used for stroke prevention). b. The MAR lacked staff signatures relating to obtaining blood pressures on the following dates: * 07/10/26; and * 07/31/26. c. Pregabalin lacked a reason for use. d. The following medications lacked clear parameters to unlicensed staff: * Nitroglycerin patch: staff to remove the patch after 12 to 14 hours from application; * Acetaminophen (used to treat pain): one to two tablets, every four hours, as needed; and * Milk of magnesia (used to treat constipation): to be used if docusate was not effective after 24 hours. Resident 1 did not have a signed order for docusate nor was it on the MAR. The need to ensure documentation on the MAR was accurate was reviewed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 1:02 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 09/2025 with diagnoses including dry eye and eye swelling. Review of the resident’s MARs, dated 07/01/26 through 08/10/26, indicated the following: a. The MAR lacked staff signatures relating to the administration of the following medications on 07/09/26: * Acetaminophen (used to treat pain); and * Hydralazine (used to treat allergies). b. The following medications lacked a reason for use: * Atropine sulfate eye drops; and * Prednisolone 1% drops. The need to ensure documentation on the MAR was accurate was reviewed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 3:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Resident 4: By 10/11/26, the facility nurse/RCC will obtain prescriber clarification and enter resident-specific PRN parameters that distinguish when acetaminophen versus oxycodone is to be used, including indication, dose, frequency, maximum limits, and when to call the nurse/prescriber. The oxycodone MAR configuration will be corrected to permit documentation of every ordered administration time. The 08/07, 08/09, and 08/10 noon doses will be investigated; late entries will not be created unless supported by reliable documentation. The resident will be assessed and the prescriber notified as clinically indicated. Resident 1: The facility nurse/RCC will investigate the 07/10/26 missing medication/treatment signatures and 07/10/26 and 07/31/26 missing blood-pressure entries, documenting whether doses/services were given or omitted and notifying the prescriber as indicated. Pregabalin's reason for use will be added. Clear signed directions will be obtained and entered for nitroglycerin patch removal, acetaminophen PRN use, and the constipation sequence involving milk of magnesia and docusate; medication staff will be informed of corrected directions by 10/11/26. Resident 3: The facility nurse/RCC will investigate the 07/09/26 missing acetaminophen and hydralazine signatures and document whether doses were administered or omitted, with prescriber notification as indicated. Reasons for use for atropine sulfate and prednisolone eye drops will be added to the MAR by 10/11/26. For all cited residents, the current MAR/TAR will be reconciled to signed orders and corrected. 2. How will the system be corrected so this violation will not happen again? By 10/11/26, the facility nurse/RCC will complete a 100% audit of current MARs/TARs for required elements: medication/treatment name, reason for use, dose, route, date/time, allergies, medication-specific instructions, resident-specific PRN parameters, staff authentication, and accurate documentation of scheduled monitoring. Medication staff will be re-educated to document during setup/pour or immediately after administration and before moving to the next resident, consistent with facility policy; to never back-chart without reliable supporting evidence; and to report blanks, unavailable documentation fields, missing reasons/parameters, or system problems before the end of the shift. The RCC/nurse will review MAR/TAR exception reports and blanks each business day. Electronic MAR configuration problems will be escalated immediately, and an approved downtime/contingency process will be used until corrected. 3. How often will the area needing correction be evaluated? The RCC or nurse designee will review MAR/TAR blanks and exception reports each business day. Defects will be investigated and corrected promptly, affected staff will be re-educated, and the record will be re-audited within seven days. 4. Who will be responsible to see that the corrections are completed/monitored? The RCC is responsible for daily MAR/TAR exception review and medication-staff follow-up. The facility nurse is responsible for clinical clarification, parameters, and prescriber notification. The Administrator is accountable for training, observation audits, and sustained compliance..

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 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate residents quarterly who chose to self-administer their medications to assure ability to safely self-administer medications and failed to have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#3) who self-administered his/her insulin. Findings include, but are not limited to: Resident 3 was admitted to the facility in 09/2025 with diagnoses including insulin-dependent diabetes. A review of the resident’s 07/01/26 through 08/10/26 MARs, current physician’s orders, dated 08/03/26, and the clinical record, dated 05/08/26 through 08/10/26, was reviewed and the following was identified. The MAR indicated the facility managed all of the medications, with the exception of insulin injections twice a day. On 08/11/26 at 1:45 pm, Staff 7 (MT) confirmed Resident 3 administered his/her own insulin. a. Resident 3 was evaluated to self-administer his/her own medications, which included insulin, on 12/02/25. There was no documented evidence the resident had been re-evaluated quarterly thereafter. b. There was no documented evidence of a current physician's or other legally recognized practitioner's written order of approval for the self-administration of insulin. The need to ensure residents who chose to self-administer their medications were evaluated quarterly to ensure their ability to safely self-administer medications and have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 1 (Administrator), Staff 2 (Regional Health and Wellness Director) and Staff 3 (RCC) on 08/12/26 at 3:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Resident 3: By 10/11/26, the facility nurse will complete and document an evaluation of the resident's ability to safely self-administer insulin, including recognition of the correct medication/dose/time, injection technique, blood-glucose monitoring, storage and sharps disposal, recognition and response to hypo/hyperglycemia, and when to seek staff assistance. A current written order approving insulin self-administration will be obtained from a legally recognized prescriber. Until both the evaluation and order support safe self-administration, the facility will manage/administer insulin according to a valid prescriber order. The service plan and MAR will be updated to clearly state resident and staff responsibilities. 2. How will the system be corrected so this violation will not happen again? By 10/11/26, the facility nurse/RCC will identify every resident who self-administers any prescription medication and audit for a current prescriber order, move-in and quarterly safety evaluations, safe storage, service-plan directions, and MAR documentation as applicable. Missing or expired requirements will be corrected immediately. A self-administration tracking log will list each resident, medication(s), prescriber-approval date, last evaluation date, and next quarterly due date. A new evaluation will also occur after a significant change, medication error, hospitalization, cognitive/functional decline, or evidence the resident may no longer self-administer safely. Care and medication staff will be educated to report unapproved self-administration, unsafe storage, missed doses, technique concerns, or condition changes immediately to the nurse/RCC. 3. How often will the area needing correction be evaluated? The facility nurse/RCC will review the self-administration tracking log monthly and 14 days before each quarterly due date and when staff have reported resident self-administration. 4. Who will be responsible to see that the corrections are completed/monitored? The facility nurse is responsible for clinical self-administration evaluations, prescriber approval, and safety decisions. The RCC maintains the tracking system and updates the service plan/MAR. The Administrator verifies timely completion and reviews audits.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: