Print Inspection: 4OLX

The findings of the re-licensure survey conducted 04/11/23 through 04/13/23 are documented in this report. The survey was conducted to determine compliance with the OAR 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OAR 411 Division 004.

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 revisit to the relicensure survey of 04/13/23, conducted 07/19/23 through 07/20/23, 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.

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 second revisit to the relicensure survey of 04/13/23, conducted 10/10/23, 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.

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 third re-visit to the re-licensure survey of 04/13/23, conducted 03/13/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was treated with dignity and respect. Findings include, but are not limited to:

Resident 1 returned to the facility after rehabilitation on 04/03/23 with diagnoses including non-displaced fracture of the surgical neck of the right arm.

Observations of the resident and interview with staff during the survey showed the resident used a wheelchair for mobility and required staff assistance with bowel and bladder management.

The service plan, dated 04/05/23, and a TSP (temporary service plan) dated 04/05/23, indicated the following:

* Staff to assist the resident with toileting and showers; and

* One person standby assist with transfers and dressing.

During an interview on 04/11/23, Resident 1 stated s/he activated the call light for bladder management on 04/08/23, but s/he did not get staff assistance. The resident further stated s/he had to urinate while s/he was on the wheelchair in the room.

The failure to provide required care and service as outlined on the service plan in a timely manner resulted in the resident being treated with a lack of dignity and respect.

On 4/13/20 at 1:30 pm, the failure to provide care and service with dignity and respect was discussed with Staff 1 (ED) and Staff 2 (District Director clinical RN). They acknowledged the findings.

Refer to C 243.

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was treated with dignity and

respect.

This incident was investiagted; both staff who were scheduled on the evening of this incident had one on one training reviewing each resident's right to dignity and respect. A training for all care staff is scheduled for May 11th, 2023 reviewing resident rights and dignity and respect. In addition to this, an immediate training was conducted with all care staff on the importance of call light responsivness and service plan compliance. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.   

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation of an event to rule-out abuse or suspected abuse or to report to the local SPD office for 1 of 1 sampled resident (#1) who was documented to have had a fall with a significant injury. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2019 with diagnoses including history of falling.

Review of Resident 1's progress notes from 01/17/23 to 04/07/23 during the survey showed the following:

* 01/08/23 staff documented the resident had a fall, was sent to the hospital and was transferred to a rehabilitation unit;

* 04/02/23 the resident had returned to the community; and

* 04/05/23 the resident sustained a nondisplaced fracture of Humerus (the bone of the upper arm) after the fall.

An investigation of the fall on 01/08/23 was requested.  On 4/12/23, Staff 1 (ED) stated there was no incident report for the fall with injury and confirmed the incident was not reported to the local SPD office.

There was no documented evidence the facility conducted an immediate investigation to reasonably conclude the fall was not the result of abuse and it was not reported to the local SPD office.

The surveyor requested Staff 1 to report the incident to local SPD office on 04/12/23. Confirmation the report had been sent to local APD office was provided.

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation of an event to rule-out abuse or suspected abuse or to report to the local SPD office

for 1 of 1 sampled resident (#1) who was documented to have had a fall with a significant injury.

Investigation of incident was completed and abuse was ruled out, APS was notified of incident. All events will have an investigation completed and documented; any events in which abuse could be suspected will be immediately reported to local SPD office. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.  

Based on observation, interview and record review, it was determined the facility failed to provide assistance with activities of daily living for 1 of 2 sampled residents (#1) who required assistance with bowel and bladder management. Findings include, but are not limited to:

Resident 1 returned to the facility after rehabilitation on 04/03/23 with diagnoses including nondisplaced right arm fracture.

Observations of the resident and interview with staff during the survey showed the resident used a wheelchair for mobility and required staff assistance with bowel and bladder management.

The service plan, dated 04/05/23, and a TSP (temporary service plan) dated 04/05/23, indicated the following:

* The resident "knows to call" for staff help with transfer;

* Staff to assist the resident with toileting and showers; and

* One person standby assist with transfers and dressing.

During the interview on 04/11/23, Resident 1 stated s/he activated his/her call light for bladder management on 04/08/23 in the evening. However, the resident stated s/he did not get staff assistance. The resident further stated s/he had to urinate while s/he was on the wheelchair in the room.

During the survey, the call light log from 04/08/23 was reviewed and revealed the following:

* The resident's call light was activated at 7:44 pm; and

* The call light was not answered until 10:31 pm, 167 minutes after the call light was activated.

On 4/13/23 at 1:30 pm, failure to provide assistance with bladder management as outlined on the service plan was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide assistance with activities of daily living for 1 of 2 sampled residents (#1) who required assistance with bowel and bladder management.

A training reviewing the importance of responding timely to call lights and following the service plan for each resident was completed on 4/25/23.  Call light times are reviewed from the day before by HWD and ED and reviewed during the morning stand up meeting with staff. All excessive call light times are reviewed and follow up is conducted with staff assigned to the resident during those shifts. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.  

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) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 moved into the facility in 01/2023.

The new move-in evaluation failed to address the following elements:

* Mental health issues including history of treatment and effective non-drug interventions;

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

* Pain including non-pharmaceutical interventions; and

* Recent losses.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/13/23. Staff acknowledged the findings.

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) whose move-in evaluation

was reviewed.

The move in evaluation process was reviewed with staff who complete the move in evaluations for our community. Training was provided to the Health and Wellness Director who completed the referenced move in evaluation. All move in evaluations moving forward will be completed with all the required elements. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 3's current service plans were reviewed during the survey.

On 04/13/23 at 10:16 am, Staff 1 (ED) confirmed the facility lacked documented evidence of a Service Planning Team to participate and review the individual service plan.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/13/23. They acknowledged the findings.

Based on interview and record review, it

was determined the facility failed to

ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person

of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar

with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed.  

Both sampled residents have service plan meetings scheduled to include the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident. All residents moving forward will have service plans developed by a service planning team. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure changes of condition were monitored at least weekly until resolved for 1 of 2 sampled residents (# 3) who were reviewed for changes of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 02/2021 with diagnoses including hypertension and cerebral infarction.  

Resident 3's progress notes and facility records dated 01/20/23 through 04/10/23 were reviewed and revealed the following changes of condition:

* Falls on: 01/21/23, 01/22/23 and 01/31/23; and

* The resident started an antibiotic on 1/25/23.

There was no documented evidence the facility monitored the changes of condition at least weekly until resolved.

The need to monitor the changes of condition at least weekly until resolved was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/13/23. They acknowledged the findings.  

Based on interview and record review, it was determined the facility failed to ensure changes of condition were monitored at least weekly until resolved

for 1 of 2 sampled residents (# 3) who were reviewed for changes of condition.

A Care Staff Meeting was conducted on 3/31/23 to review alert charting and changes of condition with care staff. Charting will be audited by the Health and Wellness Director, ED, or designee weekly to ensure residents are being monitored until resolved. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.   

2. Resident 5 was admitted to the facility in 06/2023 with diagnoses including anxiety disorder.

Progress notes and Temporary Service Plans (TSP) dated 06/26/23 through 07/18/23 indicated the following:

* 06/26/23: New environment, move-in.

There was no documented evidence the change was monitored through resolution.  

On 07/20/23, the above finding was reviewed with Staff 7 (ED 2) and Staff 8 (ED 3). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and interventions determined, documented, and monitored until resolution for 2 of 2 sampled residents (#s 4 and 5) ) who experienced changes of condition. This is a repeat citation. Findings include, but not limited to:

1. Resident 4 was admitted to the facility in 06/2023 with diagnoses including type two diabetes and chronic kidney disease.

A review of the resident's clinical records, from 06/12/23 through 07/20/23, indicated the resident moved into the facility from independent living following a 51-day stay at an acute rehabilitation center. The following changes of condition had not been reviewed by the facility or monitored to resolution:  

* There was no evidence the facility had monitored the resident after the initial move-in regarding his/her adjustment to a new living environment; and

* On 06/21/23 a HH PT provider collaboration note documented that the resident "expresses signs of depression."

During the survey, the resident was observed and interviewed on 07/20/23 at 10:20 am in his/her apartment, sitting in a recliner chair. While talking with the surveyor, the resident expressed a disinterest in participating in physical therapy and leaving his/her apartment.

According to a staff interview on 07/20/23 at 11:00 am, Staff 14 (MT) revealed:

* Resident 4 stayed in his/her apartment all day and did not attend meals in the dining room;

* The resident was not actively participating in PT and was not interested in activities; and

* At times required a two-person assist with transfers and repositioning.

On 07/20/23 at 11:45 am, Staff 9 (Health Wellness Director, LPN) indicated the resident was more socially withdrawn and had a decreased appetite.

The resident continued to display mood disturbances, and there was no documented evidence the facility had evaluated the resident, determined an action or intervention, nor was the resident's status monitored until resolution.

The changes of condition were reviewed and discussed with Staff 7 (ED 2) and Staff 8 (ED 3) on 07/20/23. They acknowledged the findings.  

1. Resident (s) will be placed on Alert charting for monitoring and outside provider notes will be reviewed for any changes and documented by appropriate staff, followed by the triple check process to ensure proper documentation.

2. All residents on Alert charting will be montiored by HWD, residents on alert will be reviewed to ensure each shift has documemented appropriatly, HWD will ensure all charting is completed and closed after appropriate documetation is completed.

3. HWD will review alert charting daily (5 days a week) for each resident that is on on alert charting or change of condition to ensure that all shifts have completed documention for alert charting and any change of condition until resolved, in the absence of HWD the RCC will ensure that all charting is completed by each shift until resolved.

The ED will ensure that this rule is met by reviewing the documentation daily (5 days a week) and reporting to the HWD and RCC for correction.

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

1. During a review of the facility's ABST on 04/11/23 through 04/13/23, it was determined the tool failed to include all of the 22 required ADL components to include:

* 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.

2. Review of Resident 1's records revealed the following:

Resident 1 was re-admitted to the facility in 04/2023 with diagnoses including the right arm fracture.

Interview with the resident and the call light log reviewed during the survey showed the resident used call light between 5 times and 10 times a day. However, the facility ABST tool failed to address the time spent for the resident's call lights.

The ABST tool was reviewed and discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/12/23 and 04/13/23. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity based staffing tool (ABST) that met the regulation.

1. Community is in process of working with Corrective Action on ABST. A call was held with the Department to review where to find 22 elements within Brookdale's Wilsonville

2. As we work through our ABST review with the department, will continue with mandated staffing which mirrors Brookdale's minimum safety guidelines.

3. We will increase our staffing as our Brookdale ABST recommends in the event that it exceeds current mandated staffing by the department.

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 implement an acuity based staffing tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to:

1. Review of Resident 4 and Resident 5's ABST records revealed the following:

* 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. During a review of the facility's ABST on 07/19/23 and 07/20/23, it was determined the tool failed to include all of the 22 required ADL components to include:

* 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 7 (ED 2) and Staff 8 (ED 3) on 07/20/23. Staff acknowledged the findings.

1. As we continue to partner with DHS on reviewing our ABST tool, we will continue to follow the minimum staffing standard as outlined in our condition.

2. Our home office team will continue to establish proper communication with DHS regarding the ABST tool and the 22 elements that make up the ABST tool, we will continue to staff according to the ABST staffing pattern

3. This will be evaluated by the HWD/RCC to ensure that proper staffing levels are scheduled according to the 22 elements

4.The Executive Director is responsible to ensure that our staffing levels are appropriate as defined by our staffing tool and our mandated staffing pattern.

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

During an interview on 10/10/23, Staff 7 (ED 2) 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 Acuity-Based Staffing Tool the facility was using didn't meet the regulation.

A review of the facility's ABST identified the tool failed to include all 22 activities of daily living (ADL's) outlined individually. It had multiple ADLs grouped together.

The ABST tool was reviewed and discussed with Staff 7 and Staff 9 (Health Wellness Director, LPN) on 10/10/23. They acknowledged the findings.

Corporate will continue to establish proper communication with DHS regarding the ABST tool and the 22 elements that make up the ABST tool, we will continue to staff according to the ABST staffing pattern

This will be evaluated by the HWD/RCC to ensure that proper staffing levels are scheduled according to the 22 elements

The ED will oversee that the staffing levels are correct according to the 22 elements.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 4, 5 and 6) completed infectious disease prevention training prior to beginning job duties. Findings include, but are not limited to:

Staff training records were reviewed on 04/12/23 and 04/13/23.

There was no documented evidence Staff 4 (MT), Staff 5 (Receptionist) and Staff 6 (Server) completed required infectious disease prevention training.

The need to ensure newly hired staff completed the required infectious disease prevention training was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 4, 5 and 6) completed infectious disease

prevention training prior to beginning job duties.

Our training program now ensures that all staff hired moving forward will complete infectious disease prevention prior to beginning their job duties. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and to provide fire and life safety instruction to staff on alternate months, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records dated 08/2022 through 03/2023 were reviewed on 04/12/23 and 04/13/23. The following was identified:

a. Fire and life safety training was not provided to staff on alternate months.

b. Fire drills were not consistently completed every other month.

c. Fire drill documentation did not consistently include one or more of the following required elements:

* Escape route used;

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

The need to follow all OFC requirements pertaining to staff instruction in fire and life safety and fire drills and documentation was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/12/23 and 04/13/23. They acknowledged the findings. No additional information was provided.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and to provide fire and life safety instruction to staff on alternate months, as required

by the Oregon Fire Code (OFC).

Fire and life safety training was provided to staff at the April All Staff Meeting on 4/28/23. A fire drill is scheduled for May 23rd, 2023. A schedule for the remainder of the year for fire drills and fire and life training will be completed and followed to ensure compliance by May 31st, 2023. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures annually. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed during the survey. The following deficiencies were identified:

* Documentation of annual fire and life safety training provided to residents.

The need to ensure residents received fire and life safety training at least annually, was discussed with Staff 1 (Executive Director) and Staff 2 (District Director of Clinical RN) on 04/12/23 and 04/13/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures annually.

A schedule has been completed to ensure all residents are instructed on the fire and life safety procedures by May 15th, 2023. Moving forward each resident will have a review of the fire and life safety procedures at their quarterly service plan meetings. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.  

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

Refer to C 270 and C 361.

See previous referral tag

Based on interview and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C 361.

See previous referal tag