Willamette View Terrace

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: 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.

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.

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.

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.

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.