Print Inspection: RL000033

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and had written, signed prescriber's orders for 1 of 5 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 01/2024 with diagnoses including congestive heart failure. Resident 1’s current facility records and 08/01/24 through 08/26/24 MAR revealed the following: a. Resident 1 had a physician order, dated 08/12/24, to obtain weight daily and “notify physician if patient gains 2 pounds in 2 days or 5 or more pounds in a week.” * Progress notes, dated 08/13/24, indicated Resident 1 had fluid removed at the hospital and s/he returned to the facility on 08/12/24 with a new weight of 226.0 lbs. The RN documented “the new weight loss noted here [226.0 lbs] is the new dry weight we are comparing for notification to the provider.” *Review of MARs revealed the following weights: 08/22/24 – 232.8 lbs; 08/23/24 – 231.8 lbs; 08/24/24 – 232 lbs; 08/25/24 – 231.6 lbs; and 08/26/24 – 231.6 lbs On 08/22/24 Resident 1’s weight increased to 232.8 lbs, a weight gain of 6.8 lbs. From 08/23/24 through 08/26/24, Resident 1’s weight was 5.6 lbs or greater from his/her baseline. During an interview on 08/28/24 at 10:45 am with Staff 17 (RCC), she indicated she was not clear what the baseline weight was to reference if Resident 1 had a weight gain that required notifying the physician. During an interview on 08/28/24 at 11:10 am, Staff 3 (RN/Health and Wellness Director) acknowledged the physician was not notified of the weight gain on 08/23/24 when resident had gained greater than two pounds in two days. The resident’s physician was notified of the weight gain on 08/27/24 during a facility visit. b. The discharge instructions, dated 08/12/24, included a signed physician’s order for “Orthostatic- (low blood pressure that occurs when standing up) VS [vital signs] daily X 2 days then PRN dizziness”. Review of Resident 1’s MAR indicated vitals were taken in the evening on 08/13/24, and in the morning on 08/15/24 and 08/16/24. The MAR was blank for morning and evening on 08/14/24 and the resident was out of the building during the evening on 08/15/24. In addition to vitals not being taken on 08/14/24, there was no documented evidence orthostatic blood pressures were taken. During an interview on 08/28/24 at 12:55 pm Staff 17 indicated the resident’s vitals were taken in the sitting position only. No additional blood pressure values were taken in other positions. c. The following medications and/or treatments lacked a signed physician’s order in the record: * Donepezil 5 mg for dementia; and * Oxygen at 1.5 L/min for respiratory failure. d. Resident 1’s MAR showed a discontinued date of 08/12/24 for sodium phosphate enema for constipation. The facility lacked documented evidence of a signed order to discontinue the medication. e. Resident 1’s After Visit Summary, signed by the physician on 08/12/24, indicated the following instructions: * Aspiration (food or drink that accidentally enters into the trachea and can pass into the lungs) precautions that included “Keep upright 90 degrees with any oral intake, small bites and sips”; and * Delirium precautions: “open window shades during the day and maximize sun exposure from 0800 to 1600” and “limit interruptions between 2200 and 0600. During an interview on 08/28/24 Staff 3 acknowledged the instructions were not carried out or clarified with Resident 1’s physician. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2 (District Director of Operations), Staff 3, Staff 6 (LPN/Health and Wellness Coordinator) and Witness 2 (Consultant) on 08/28/24. They acknowledged the findings. No further information was provided.

1. Resident 1: A. The provider was contacted by the Health and Wellness Director and a discussion of current weight, changes in weight, and orders was held. Her daily weights since readmission were reviewed, current lower extremity edema, and SPO2 readings while at rest and while ambulating were evaluated. 2. System Correction: Training with med techs was conducted and education done on : daily or weekly weights, the reason for, and how to monitor and notify appopriatley,. Weekly review by clinical leadership of all person on daily or weekly weights. 3. Review of weights will occur weekly by clinical leadership including RN/LN. When it is determined that a resident has a new baseline weight the new benchmark will be added to the residents electronic medical record by the Health and Wellness Director or designee. 4. Executive Director and Health and Wellness Director Resident 1 B. 1. The standard block discharge orders from the after visit summary were reviewed with the primary care provider and an order was obtained to discontinue these orders. B. 2.System Correction: Staff training for the medication aides as well as the Health and Wellness Director and the Health and Wellness Coordinator was conducted on entering of all signed orders included in the aftervisit summary. Training included sending the after visit summary or orders to the primary care provider for notification of new orders. B. 3. All orders will go through a three step system of verification: Step 1: The person receiving the order during their shift will review and transcribe any new orders that come in during their shift. Step 2- The order is placed in the folder in the medication room that is labeled with the Health and Wellness coordinator or Executive Director for a second check of the accuracy of the orders transcribed. Step 3. Orders are placed in the folder marked Director of Health and Wellness and will have a third and final check for accuracy conducted. C. Monitoring All orders processed will be reviewed in the clinical meeting each morning. In the case of weekends, the Clinical leadership in the building will review the orders for accurracy and contact the licensed nurse on call if any questions or inaccurracies found. Resident 1 C. 1. The written and signed physicians orders for the medication noted were located and placed in the chart. C 2. System Correction: Organization of the medication room area including labeling of folders for orders being processed and seperating of paperwork into separate holders was done to decrease confusion on placement. C. 3 Monitoring C.4. Responsible Party Health and Wellness Director Resident 1 D. 1. Orders were obtained by the provider to discontinue the medications that had been removed from the residents record. D. 2 System Correction Staff education was done on obtaining an order to discontinue unused as needed medications before discontinuing them. D. 3 Monitoring E. Responisible Party Health and Wellness Director E. Resident 1 SEE B ABOVE

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: 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 orders for 1 of 1 sampled resident (# 1), who had documented treatment refusals. Findings include, but are not limited to: Resident 1 was admitted to the facility in 01/2024 with diagnoses including congestive heart failure. Resident 1's MARs, dated 08/01/24 through 08/26/24 were reviewed and revealed facility staff documented Resident 1 refused the following orders: * Miconazole cream twice daily (for rash) on 12 occasions; * Petroleum jelly gel twice daily (for skin dryness) on four occasions; and * Daily weights on one occasion. On 08/28/24, Staff 3 (Health and Wellness Director/RN) confirmed there was no documented evidence the practitioner was notified of the multiple treatment refusals. The need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (Executive Director), Staff 2 (District Director of Operations), Staff 3, Staff 6 (LPN/Health and Wellness Coordinator) and Witness 2 (Elderwise Consultant) on 08/28/24. They acknowledged the findings, and no additional documentation was provided.

1. Hold training with med techs to discuss: how to notify physicians of refusals and how to document refusals. Refusals will be done via fax. 2. Weekly review by clinical leadership/ED of all refusals to ensure notifications have been done. 3. Review of refusals will be done weekly. 4. Executive Director and Health and Wellness Director

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0037 (3)(a-v) Acuity Based Staffing Tool: Care Elements (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: 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: There was no documented evidence the facility was using an ABST that included all the required ABST elements. In an interview on 08/27/24 at 11:15 am, Staff 1 (ED), Staff 2 (District Director of Operations), Witness 1 (Elderwise Consultant) acknowledged the facility's ABST failed to separately list all twenty-two required ADL questions for each resident. On 08/27/24, the need to ensure the facility implemented an ABST which included all required elements was reviewed with Staff 1, Staff 2, and Witness 1. They acknowledged the findings.

1. Community is in process of working with Corrective Action Team on reviewing Brookdale’s Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate 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 Brookdale’s tool. 3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly. 4. Executive Director or designee

OAR 411-054-0037 (3)(a-v) Acuity Based Staffing Tool: Care Elements (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: 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: There was no documented evidence the facility was using an ABST that included all the required ABST elements. In an interview on 11/25/24 at 2:11 pm, Staff 1 (ED) and Staff 2 (District Director of Operations) acknowledged the facility's ABST failed to separately list all twenty-two required ADL questions for each resident. On 11/25/24, the need to ensure the facility implemented an ABST which included all required elements was reviewed with Staff 1 and Staff 2. They acknowledged the findings.

OAR 411-054-0037 (3)(a-v) Acuity Based Staffing Tool: Care Elements (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on 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 C362.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 08/26/24 at 10:40 am. The following was found to be in need of repair: Two light fixtures located on the second floor were missing covers. One fixture was located at the top of the stairwell in the hallway near apartment 233. The second fixture was located in the hallway next to apartment 223. The building was toured with Staff 4 (Maintenance Supervisor) on 08/27/24 at 2:45 pm. During the tour Staff 4 stated the light covers were currently “out of stock”. In an interview with Staff 1 (ED) on 08/27/24 at 3:05 pm, Staff 1 was aware of the missing light covers and stated the facility is “trying to source them” because they are no longer made. The need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 4 on 08/27/24 at 2:45 pm and Staff 1, Staff 2 (District Director of Operations), and Witness 2 (Elderwise Consultant) on 08/28/24 at 11:40 am. The findings were acknowledged.

1. Light fixtures to be replaced that were missing covers. 2. Light fixtures to be replaced as issues occur. 3. Weekly walk through to be completed. 4. Executive Director and Maintenance Supervisor

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: