The findings of the re-licensure survey, conducted 07/29/24 through 07/31/24, 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 for 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 first re-visit to the re-licensure survey of 07/31/24, conducted on 10/17/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for 2 of 2 sampled residents (#s 3 and 5), who had documented treatment refusals. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2022 with diagnoses including heart failure and allergies.

The resident's MAR, dated 07/01/24 through 07/28/24, was reviewed and revealed facility staff documented Resident 3 refused the following treatment orders:

* Daily weights on three occasions;

* Ipratropium bromide (for allergies) on 30 occasions;

* Nystatin powder (for skin redness or irritation) on 27 occasions; and

* Triamcinolone cream (for skin irritation) on 25 occasions.

There was no documented evidence the facility notified Resident 3's physician of the refusals.

On 07/31/24, the need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (Administrator). He acknowledged the findings, and no additional documentation was provided.

2. Resident 5 was admitted to the facility in 05/2023 with diagnoses including back pain.

Review of the resident's 07/01/24 through 07/29/24 MAR and current physician orders showed the following:

* Resident 5 was prescribed Dicolofenac Sodium topical gel for pain; and

* The resident refused the Diclofenac Sodium topical gel 21 times between 07/01/24 through 07/29/24.

There was no documented evidence the prescriber was notified of the resident's refusal to consent to the treatment order.

The need to ensure the facility notified the prescriber or physician when a resident refused consent to an order was discussed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings.

1. Meeting held with Executive Director, Registered Nurse, RCC and medication dispensing staff to discuss the rule violation C305 in detail and new protocols in place, notifying PCPs of resident medication and weight refusals.

2. Redwood Terrace has requested all resident PCP's (primary care providers) to advise the community how often per month they would like to be notified of medication and/or weight refusals. All PCP's were notified via fax with this request. This also includes resident 3 & 5 as listed on SOD.

3. Weekly system review by community RN and RCC including a refusal report review from current electronic E-Mar system.

4. This correction will be monitored weekly by the Registered Nurse, RCC and Executive Director for accuracy to ensure the rule is met.  

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and non-pharmacological interventions for staff to attempt and document as ineffective prior to administering the PRN medication for 1 of 1 sampled resident (#5) who was prescribed PRN psychotropic medications. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 05/2023 with diagnoses including Schizoaffective disorder, generalized anxiety, and depression.

Review of the resident's 06/01/24 through 07/29/24 MARs and current physician orders showed the following PRN psychotropic medications:

* Hydroxyzine Pamoate 25 mg, take 3 capsules (75 mg) by mouth two times daily, as needed for anxiety.

The facility administered the Hydroxyzine Pamoate to the resident on seven occasions between 06/01/24 and 07/29/24.

* Lamotrigine 100 mg tablet by mouth every day as needed for depression.

The facility administered the Lamotrigine on eight occasions between 06/01/24 and 07/29/24.

* There was no documentation of resident-specific parameters for these PRN psychotropic medications; and

* There was no documentation of what non-pharmacological interventions were attempted with ineffective results prior to the administration of the PRN medications.

The need to ensure there were resident-specific parameters for all PRN psychotropic medications, that non-pharmacological interventions were documented in the resident record and all direct care staff had knowledge of them, and that staff attempted non-pharmacological interventions and documented them as being ineffective prior to administering a PRN psychotropic, was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 07/31/24. They acknowledged the findings.

1a. Meeting conducted with Executive Director, Registered Nurse, Resident Care Coordinator and Assistant Director to discuss root cause of citation.

1b.Full review of all PRN Psychotropic medications conducted by Registered Nurse. Corrections were made including added non pharmcological interventions and resident specific parameters.

1c. Meeting held with Executive Director, Registered Nurse, RCC and medication dispensing staff to discuss rule violation C330 Psychotropic medications in detail, review rule and changes made for correction

2.Registered Nurse will conduct weekly audits of PRN Psychotropic medications use as well as resident specific parameters and non pharmacological interventions. Changes and revisions were made to Resident 5 as listed on the SOD.

3. Evaluated weekly by Registered Nurse.

4. The Registered Nurse and Executive Director will be responsible for weekly oversight to ensure the rule is properly met.