The findings of the re-licensure survey, conducted 06/13/23 through 06/15/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 06/15/23, conducted on 10/25/23 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, OARs 411 Division 57 for Memory Care Communities, 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

Based on observation, interview and record review, it was determined the facility failed to provide assistance with activities of daily living for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 01/2015 with diagnoses including Alzheimer's disease.

Observations of Resident 1 during the survey revealed s/he was dependent on staff for all ADL care including incontinent care.

The service plan, dated 04/27/23, indicated staff were to "provide toileting assist on a schedule every 2-3 hours and as needed."

On 06/14/23, at 9:00 am, the resident was observed in the living room, watching television with peers. S/he stayed there until 11:30 am, when s/he was escorted to the dining room for lunch. S/he was in the dining room until 12:30 pm, then escorted back to the living room. At 12:53 pm, Staff 15 (CG) and Staff 18 (CG) arrived to assist the resident into bed. During the transfer, the resident was noted with incontinence of bladder on his/her clothes, the mechanical lift sling and blanket underneath him/her. Staff 15 and Staff 18 proceeded to change the resident's brief at 1:00 pm.

During an interview on 06/14/23 at 1:00 pm, Staff 15 stated the resident had not been changed since 8:00 am that morning.

The need to ensure the facility provided assistance with activities of daily living to residents was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 06/15/23. They acknowledged the findings.

1. Immediate re-training was completed 06/16/2023 by RCC to all shifts regarding residents toileting schedule. Resident #1 has been toileted per their service plan as of 06/16/2023. All residents with toileting schedules had their service plan reviewed as of 08/12/2023. Extra slings were purchased for all Hoyers. Personal Service Plan updated in the system. Updated Personal Service Plan is always avalible to the staff to review and sign.

2.Continuous In-Service for all Direct Care Associates on resident #1 and all residents on a toileting schedule, service plans have completed by RCC,HWD on 06/16/2023.

3.Quarterly training will be done by RCC, HWD and designee.

4. HWD and ED, or designee will be responsible for ensuring the above system on a quarterly basis.  

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols for 1 of 1 sampled resident (#1) and to designate an individual to be the facility's trained infection control specialist. Findings include, but are not limited to:

Observations made during the survey, 06/13/23 through 06/14/23, determined the facility failed to adhere to universal precautions for infection control in the following areas:

1. During an interview with Staff 1 (ED), on 06/13/23, she confirmed the facility had not designated an individual to be the facility's "Infection Control Specialist" and ensure an Infection Control Specialist was trained, as required.

2. On 06/13/23 at 11:10 am, Staff 15 was observed to comb Resident 1's hair while s/he was sitting in the living room. Staff 15 proceeded to approach two unsampled residents and comb their hair with the same comb.

3.  On 06/14/23, At 10:15 am, Staff 10 (MT) was observed delivering snacks to the living room area where residents were watching television. Staff 15 (CG) was observed to pass the snacks out to residents without first performing hand hygiene. Staff 15 was observed to then collect the trash from residents who had finished eating, including banana peels from the floor and used cups, Staff 15 then proceeded to feed Resident 1 without first performing hand hygiene.

4. Resident 1 was admitted to the facility in 01/2015 with diagnoses including Alzheimer's Disease. Observations and interviews with staff during the survey identified s/he relied on staff for incontinent care needs.

On 06/14/23 at 1:00 pm, Staff 15 (CG) and Staff 18 (CG) were observed providing ADL incontinent care for Resident 1. During the observation, Staff 15 and Staff 18 donned gloves without performing hand hygiene. Staff 15 and Staff 18 proceeded to remove the soiled incontinent brief, perform perineal care with wipes and apply barrier cream to the resident's skin while wearing soiled gloves. Staff 15 and Staff 18 failed to doff soiled gloves, perform hand hygiene and don clean gloves before touching the resident's body and clean incontinent products.

Staff 15 was observed placing soiled clothes and linen in Resident 1's laundry basket without bagging the soiled clothing. Staff 15 also placed the soiled lift sling back on the mechanical lift. Neither Staff 15 or Staff 18 were observed to disinfect the soiled geri chair. Staff 18 was observed, while still wearing soiled gloves, to pick up the bag with the soiled brief, open Resident 1's door, and took the bag to the shower room in the 'F' hall. Staff 18 deposited the bag, removed the soiled gloves, and proceeded to walk back to the living room area. No hand hygiene was observed. Staff 15 was later observed wheeling Resident 1's geri chair throughout the facility with the soiled laundry placed directly on the chair.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1, Staff 2 (RN), and Staff 3 (RCC) on 6/15/23. They acknowledged the findings.

1. A. Immediate re-training was completed on 06/16/2023 by RCC regarding treating all residents with dignity and respect.

B.Immediate training on ( hand-hygiene) proper hand washing policy and procedure completed 06/14/2023 and on going.

C. proper handling of soiled clothes an linen completed 06/14/2023

D. RCC or designee completed the Infection Control Specialist Training online on 06/14/2023 and all staff members to complete the 2 hour course for Infection control training.

2. Continuous training for the assoicates was completed by RCC on 06/14/2023 and 06/16/2023. Staff #15 was immediately in serviced on 06/14/2023 for Infection Control training and proper handling of soiled clothes and linens on 06/14/2023Staff #10 was immediately re-trained for proper handwashing policy and procedure, completed 06/14/2023.

3.RCC, HWD or ED will be doing walk through throughout the community every shift to observe all Direct Care Associciates.

4. HWD and ED, or designee will be responsible for ensuring the above system is correct.

Based on interview and record review, it was determined the facility failed to ensure the specific reasons for use for PRN psychotropic medications were included on the MAR and non-pharmacological interventions had been documented as attempted and ineffective prior to administering the medication, for 2 of 2 sampled residents (#s 4 and 5) who were administered PRN psychotropic medications. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2022 with diagnoses including psychotic disturbance, mood disturbance, anxiety, and dementia.

Review of the record indicated Resident 4 had orders for, and was administered, PRN Lorezepam "for anxiety/agitation" on 6 occasions from 05/24/23 through 05/29/23. The following were identified:

* There were no specific reasons for use documented on the MAR which described how Resident 4 exhibited "anxiety/agitation";

* There were no non-pharmacological interventions listed for staff to attempt prior to considering administering the medication; and

* The facility failed to document non-pharmacological interventions were attempted and were ineffective prior to administering the medication.

The need to ensure there were specific reasons for use and non-drug interventions were attempted and ineffective prior to administering a PRN psychotropic medication was reviewed with 1 (ED), and Staff 2 (RN) on 06/15/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease, vascular dementia, paranoid schizophrenia, depression and bipolar disorder.

Review of the record indicated Resident 5 had orders for and was administered PRN clonazepam "for anxiety/agitation" on seven occasions from 06/01/23 through 06/09/23. The following were identified:

There were no resident-specific parameters documented on the MAR which described how Resident 5 exhibited "anxiety/agitation".

The need to ensure the MAR included resident-specific parameters was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 06/15/23. They acknowledged the findings.

1.Resident 4 and 5 MAR was reviewed on 06/14/2023 and updated with resident spexific interventions and perameters

2.All remaining MARs for residents on PRN psychotrpoic medications were reviewed and resident specific interventions and perameters were added as appropriate by 07/05/2023

3.HWD in-serviced on adding perameters and clarifications to MARs and CBC psycotropic medication training on 07/07/2023

4.HWD reviewed all new PRN psychotropic medication orders and will add resident specific interventions and perameters as part of a 3 check system daily when in and will review and add additional updates as needed at clinical meeting daily when in  

Based on interview and record review it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. Findings include, but are not limited to:

During an interview on 06/14/23, Staff 1 (ED), stated the facility was using the "Brookdale ABST" and she was aware that the Department had previously placed a condition on the facility's license because the ABST the facility was using didn't meet regulation.

A review of the facility's Acuity Based Staffing Tool (ABST) identified the following:

1. The ABST tool failed to include all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide each task.

2. The ABST had multiple ADLs grouped together in subcategories. For example, dressing was grouped together with grooming.

3. The tool failed to address the following ADL's, individually:

* Personal hygiene;

* Transfer in and out of bed or a chair;

* Repositioning in bed or chair;

* Assisting with leisure activities;

* Assisting with communication, assistive devices for hearing, vision, speech;

* Responding to call lights; and

* Safety checks, fall preventions.

The ABST tool was reviewed and discussed with Staff 1 and Staff 3 (RCC) on 06/14/23. They acknowledged the findings.

1. Community in process of working with Corrective Action on reviewing Brookdales Acuity Based Staffing Tool. There have been multiple calls and communication with the Department and we are continuing to staff using our tool as well as where the 22 required elements are identified.

2. As we work through our Acuity Based Staffing Tool (ABST) with the department, we will continue to staff using Brookdales Tool.

3. We will continue to evalutate and modify our staffing needs through our resident asseesment process to include upon move in, change of condition, and quarterly.

4. The Executive Director and/or designee is respoinsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to:

The facility's ABST was reviewed on 10/25/23.

There was no documented evidence all 22 required ADLs were addressed separately on the acuity-based staffing tool the facility was using.

During an interview on 10/25/23 at 10:45 am, Staff 1 (ED) confirmed all required ADLs were not addressed separately on the facility's acuity-based staffing tool.

The need to have all required ADLs listed separately on the ABST was discussed with Staff 1 on 10/25/23. No further information was provided.

1. Community in process of working with Corrective Action on reviewing Brookdales Acuity Based Staffing Tool.We are currenlty sending our Bi weekly reports with ABST hours and schedule of staff. Reports are being emailed to Kelsie Norton. (ABS Corrective Action Cordinator)

2.As we work through our Acuity Based Staffing Tool  (ABST) with the department, we will continue to staff using the Brookdale tool

3.We will continue to evaluate and modify our staffing needs through our resident assesment process to include upon move in,change of condtion,and quarterly.

4.The Executive Director and/or designee is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure that residents were relocated/evacuated during fire drills according to the Oregon Fire Code and fire and life safety training for staff was provided on alternate months. Findings include, but are not limited to:

A review of fire and life safety records provided from 12/2022 through 05/2023 identified the following:

1. Fire drills conducted did not include the following information:

* Evacuation time period needed; and

* Number of occupants evacuated.

During an interview on 06/14/23, Staff 6 (Maintenance Director), stated the facility had not routinely relocated residents during fire drills.

2. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of the fire drills.

The need to ensure residents were relocated/evacuated during fire drills and fire and life safety instruction was completed on alternate months in accordance with Oregon Fire Code, was discussed with Staff 1 (ED) and Staff 6 on 06/15/23. They acknowledged the findings.

1.Fire and safety binder was audited for missing documentation. We scheduled an ALL-STAFF training starting July 2023 to go over previously missed monthly training documentation.

Floor plan of community will be drawn up for new alternative routes for evactuation. Live evacuation with residents will be done as needed.

2&3.Fire and safety trainings are reviewed monthly to ensure no fire and safety trainings have been missed and to ensure all fire and safety training topics have been reviewed by the end of each year.

4.The ED,BOC and MD will all be responsible for ensuring corrections are made.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:

Refer to C 361.  

Refer to C-361

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and clothing, and the soiled linen area included a flushing rim clinical sink with a handheld rinsing device. Findings include, but are not limited to:

The six facility laundry rooms were observed on each unit on 06/14/23 with Staff 6 (Maintenance Director). The following was observed:

a. The facility used residential type washers. Staff 6 (Maintenance Director) stated there was no way to determine the rinse temperature. The detergent the facility used did not include a disinfecting agent for use on soiled linens.

b. Laundry rooms included signs instructing staff that soiled linens and clothing should be processed in laundry rooms "A-Hall" and "D-Hall" only. During a tour on 06/15/23, Staff 1 (ED) acknowledged laundry rooms "A" and "D" did not have a flushing rim clinical sink. Laundry rooms in "E" and "C" halls had utility sinks with no handheld rinsing device. Staff 1 acknowledged the facility needed to determine a new process for soiled linen processing.

The need to ensure soiled laundry was properly disinfected and the facility had a flushing rim clinical sink with hand held rinsing device for processing soiled linen was discussed with Staff 1 and Staff 6 on 06/15/23. They acknowledged the findings.

1.on 06/03/2023 new chemical disinfectant was ordered from Eco Labs to wash soil linens. On 06/16/2023 took pictures with maintenance. Working with regional maintenance director to purchase and install flushable rinse sinks.

2.The community will continue to order the correct laundry disinfectant. The flushable sinks will be installed to process soiled linens. Continuance requested we are ordering and cordinating construction of new flushable sinks.

3&4. Maintenance will be responsible for ordering the correct disinfectant when needed and will ensure flushable sinks ( once installed ) remain in working order.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 295, C 361, C 420 and C 530.

Refer to C295, C361,C420,and C530

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 361.  

Refer to C-361

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long term, direct care staff sampled (#s 10, 11 and 20) completed a total of 16 hours of in-service training annually. Findings include, but are not limited to:

Staff training records and the facility's staff training program were reviewed on 06/13/23 and 06/14/23. The following were identified:

Annual staff training records provided lacked documented evidence a total of 16 hours of annual in-service training completed, which included 6 hours of dementia care training, for Staff 10 (Lead MT) hired 11/30/2011, Staff 11 (MT) hired 07/30/2018, and Staff 20 (CG) hired 09/06/12 whose records were reviewed for the past year from their anniversary hire date.

The need to ensure long term direct care staff completed all required annual training was reviewed with Staff 1 (ED) and Staff 5 (Business Office Manager) on 06/15/23. They acknowledged the findings.

1. Training records in the community have been compiled into an organized system and documented on a tracker to show what training each current associate has completed.

2.Training courses have been scheduled monthly to start in July 2023 to have all associates attend to make up the missing training items.Each associate will have completed all needed trainings monthly and by their anniversary hire date.

3&4. BOC will check the organized tracker on a two week bases to ensure all associates are up to date with all needed trainings. In addition, the tracker will be checked upon the time of hire for a new associate.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 243 and C 330.

Refer to C243 and C330.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of their rooms. Findings include, but are not limited to:

During the survey from 6/13/23 to 6/15/23, observations of resident rooms revealed multiple rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff.

During an interview on 6/14/23 at 12:55 pm, Staff 15 (CG) stated resident room doors were locked because some residents wander into others' rooms. Staff 15 stated all the caregivers had keys and could escort residents into their rooms.

On 06/14/23, at 1:05 pm, an unsampled resident was heard trying to enter his/her room while staff were providing ADL care to his/her roommate. A few minutes later, Staff 3 (RCC) opened the room door to allow the unsampled resident to enter. The unsampled resident was observed to ask for a key to the room, stating, "and then I don't have to bother you to get into my room."

The need to ensure residents were not locked outside of their rooms was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 06/15/23. They acknowledged the findings.

1.Training was completed by RCC and ED on 06/15/2023 to make sure residents rooms were not locked. Training on residents rights where addressed. Staff #15 was present during the training.

2. Continuous training for staff to remind them not to lock residents room, unless requested and stated in a residents service plan.

3.RCC,HWD or designee will be doing random walk through the community to assure that we are incompliance.

4.HWD and ED, or deignee will be responsible for ensuring the above system is corrected.