The findings of the re-licensure survey conducted 10/18/21 through 10/19/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 10/19/21, conducted 12/16/21, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2021.

Resident 2's move-in evaluation failed to address the following:

* Personality, including how the person copes with change and challenging situations; and

* Environmental factors that impact the resident's behavior.

The failure to address all required areas in the move-in evaluation was shared with Staff 1 (Health Care Services Administrator), Staff 2 (Director of Nursing) and Staff 3 (RN) on 10/19/21. They acknowledged the findings.

1. Resident #2 has been evaluated for the following areas: Personality, including how they cope with change or challenging situations, environmental factors that impact their behavior.

2. Each Terrace resident will be evaluated for the following areas: Personality, including how they cope with change or challenging situations, environmental factors that impact their behavior.

3.The Basic Level of Care evaluation will be updated to address the areas of resident personality including how they cope with change and challenging situations and environmental factors that impact the resident's behavior.

4. A monthly audit of all the completed Basic Level of Care Evaluations will be conducted by the DNS or designee to assure compliance in completing the areas addressing resident personality including how they cope with change and challenging situations and environmental factors that impact the resident's behavior. Audit results will be reported to the Quality Assurance Committee and the frequency of future audits adjusted as needed.

Based on interview and record review, it was determined the facility failed to ensure a resident who self-administered medications was evaluated at least quarterly to ensure they were safe to do so, for 1 of 1 sampled resident (#2) who self-administered medications. Findings include, but are not limited to:

Resident 2 was admitted to the facility on 08/2021 with diagnoses including dementia.

Review of the resident's 08/30/21 signed physician orders and the October MAR indicated the resident had an order to self-administer Miralax (for bowel care), Glucose tablets (for hypoglycemia) and Ipratropium nasal spray (for allergies). The facility administered all other medications for the resident.

There was no documented evidence a self-medication evaluation had been completed by the facility.  

The need to ensure a quarterly self-medication administration evaluation was completed for each resident who wished to self-administer medications was discussed with Staff 1 (Health Care Services Administrator), Staff 2 (Director of Nursing) and Staff 3 (RN) on 10/19/21. They acknowledged the findings.

1. The facility will evaluate Resident #2 for their ability to safely self-administer medications.

2. The facility will audit the Physician's Orders of all residents to identify those with orders to self-administer medication(s).  The facility will assure that a Self- Medications Evaluation has been completed within the past 90 days for each resident with an order to self-administer medications.

3. Licensed nurses will be re-educated regarding the facility policy regarding self-administration of medication and Self- Medication Evaluations,

4. A monthly audit will by conducted by the DNS or designee to assure that each resident with a physician's order to self-administer medication has a Self-Medication Evaluation completed within the past 90 days. Audit results will be reported to the Quality Assurance Committee and the frequency of future audits adjusted.

Based on interview and record review, it was determined the facility failed to ensure  documented non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed a PRN medication for anxiety and delusions. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 04/2021 with diagnoses including delusional disorder.

Resident 4 had a physician's order for Quetiapine Fumarate 50 mg every four hours as needed for anxiety and delusions. The medication was administered on 10/09/21, 10/16/21 and 10/22/21. There was no documented evidence non-drug interventions were attempted with ineffective results prior to administration of the medication.

In a interview on 10/19/21, Staff 3 (RN) confirmed the facility lacked documentation non-drug interventions were tried and ineffective prior to the administration of the medication.

The requirement to have non-pharmacological interventions developed and attempted with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing) and Staff 3 on 10/19/21. They acknowledged the findings.

1. The physician of resident #4 has adjusted to PRN quetiapine order to read that the resident is "able to direct PRN usage."

2. Residents with a PRN psychotropic order used to treat behaviors will have resident specific interventions listed on the eMAR to trial before administering the PRN medication unless their physician specifies, they have the ability to direct the usage of the PRN medication.

3. Facility staff will be educated regarding the need to trial the resident specific interventions & document their effectiveness prior to administering any PRN psychotropic medication.

4. Monthly audits of the eMAR will be conducted to assure facility staff are utilizing the resident specific interventions prior to administering a PRN psychotropic medication.

5. Audit results will be reviewed with the Quality assurance Committee and the frequency of future audits adjusted.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records, reviewed between 04/2021 and 09/2021 revealed fire drill records lacked the following components:

* Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and

* Number of occupants evacuated.

In an interview on 10/19/21 at 11:20 am, Staff 1 (Maintenance Specialist) acknowledged fire drill records lacked all required components.

The need to ensure fire drill records contained all required components was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing) and Staff 3 (RN) on 10/19/21. They acknowledged the findings.

1. A review of all fire drill requirements & fire drill documentation requirements will be completed.

2. The Fire Drill form and procedure will be adjusted to include escape route used, number of occupants evacuated, and problems encountered and comments relating to residents who resisted or failed to participate in the drills.        

3. Staff will be educated regarding the fire drill requirements and fire drill documentation requirements.

4.  Fire drills will conducted using the revised form.

5. Fire drill documentation will be audited monthly by the Administrator or their designee.

6. Audit results including recommendations for improvement will be presented to the Quality Assurance Committee.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records for 04/2021 through 09/2021 were reviewed on 10/19/21.

The facility lacked documented evidence of the following:

* Evidence alternative exit routes were used during fire drills; and

* Evidence staff were aware of the designated point of safety.

The need to ensure general fire and life safety requirements were met was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing) and Staff 3 (RN) on 10/19/21. They acknowledged the findings.

1. A review of all fire drill requirements & fire drill documentation requirements will be completed

2. The Fire Drill form will be adjusted to include evidence that alternative exit routes were used and evidence that staff were aware of the designated point of safety   

3. Staff will be educated regarding the fire drill requirements and fire drill documentation requirements

4.  Fire drills will conducted using the revised documentation form.

5. Fire drill documentation will be audited monthly by the Administrator their designee.

6. Audit results including recommendations for improvement will be presented to the Quality Assurance Committee.