Cascade Terrace Post Acute

record accurately and gave Staff 2 the paper order for temozolomide which was provided by the clinic. On 11/5/25 at 11:58 AM, Staff 23 stated she received a phone call from Witness 3 in 5/2025 after Resident 2 returned from an appointment at the neuro-oncology clinic.

Staff 23 stated she was informed by Witness 3 the resident was not supposed to receive temozolomide past 4/26/25.Attempts to contact Witness 3 on 11/4/25 and 11/5/25 were unsuccessful. On 11/5/25 at 1:01 PM, Staff 24 (Medical Director) stated Resident 2 was supposed to receive temozolomide for five days in 4/2025 but received the medication longer than ordered.

Staff 24 stated he expected nurses to contact the prescriber of resident medications to get clarification with any order that was ambiguous and that Resident 2's 4/21/25 order for temozolomide was unclear.

Staff 24 further stated this incident was a big mess up which resulted in Resident 2 going back-and-forth to the hospital.On 11/6/25 at 11:04 AM, Staff 2 stated Resident 2 returned from her/his appointment on 4/21/25 with a Neuro-Oncology Consult Encounter Note which noted the resident's current medication list was to include 390mg temozolomide taken once daily at bedtime on days one to five of a 28-day treatment cycle.

Staff 2 stated this note did not constitute an order for the medication.

Staff 2 stated she completed a lengthy investigation of this medication error and was never able to find a paper order from the resident's neuro-oncology clinic for the temozolomide.

Staff 2 denied ever visualizing a paper order for the medication or checking Staff 22's entry into Resident 2's clinical record regarding the medication.

Staff 2 stated Staff 22 should have contacted Witness 2 on 4/21/24 and requested clarification for the temozolomide order in writing.

The deficient practice was identified as Past Noncompliance based on the following:On 5/20/25, the deficient practice was identified by the facility and was corrected when the facility completed an investigation of the incident and determined the medication was administered for an excessive duration.

The Plan of Correction included:1.

Licensed nurses were educated on the process for obtaining paper copies for all prescriptions from any outside medical provider, and all prescriptions entered into a resident's medical record required a second licensed nurse to sign off for accuracy. 2. An audit of MARs was completed for all residents to ensure paper copies for all prescriptions from any outside provider were obtained and two licensed nurse signatures were present. 3.

Weekly medication prescription audits were completed by Staff 2 for four weeks.

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