Print Inspection: XVS5

The findings of the re-licensure survey, conducted 02/16/22 through 02/18/22, 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 Home and Community Based Services Regulations OARs 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 re-visit to the re-licensure survey of 02/18/22, conducted 07/13/22, 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. It was determined the facility was in substantial compliance.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were reviewed upon entering the facility on 02/16/22. The following deficiencies were identified:

Multiple staff were observed wearing cloth face masks or face coverings rather than the required medical-grade face masks.

The facility was immediately instructed by the survey team to resume using medical-grade face masks. The facility began to implement proper use of Personal Protective Equipment (PPE) on 02/16/22.

The need to ensure the facility exercise reasonable precautions against any condition that could threaten the health, safety and welfare of residents was discussed with Staff 1 (Administrator) on 02/16/22. He acknowledged the findings.

1.

The facility Administrator re-implemented proper use of Personal Protective Equipment on 02/16/2022. The Administrator immediately instructed all staff to resume using only medical grade face masks. The Administrator, Designee and LN will continue to always make medical grade face masks available to staff at all times. Appropriate monitoring will take place by Administrator, Designee or employee in charge, for all shifts and all times.

2.

New hires will be informed of proper use of Personal Protective Equipment upon hire. Administrator, Designee and the LN will train all staff members regarding proper use of PPE and will enforce the policies regarding proper use of PPE. On-going training and reminders will be provided to staff at Monthly All Staff Meetings and as needed.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements, for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

Resident 2's move-in evaluation, dated 12/27/21, lacked information regarding the following required elements:

* Customary Routines including sleeping, eating and bathing;

* Interests, hobbies, social, and leisure activities;

* List of current diagnosis;

* List of medications and PRN use;

* Visits to health practitioners, ER, hospital or NF in the past year;

* Vital signs if indicated by dx, health problems, or medications;

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

* Pain: pharmaceutical and non-pharmaceutical interventions, including how the person copes with pain;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements;

* Elopement risks;

* Alcohol or drug use; and

* Environmental factors that impact behavior including but not limited to noise, lighting and room temperature.

The need to ensure initial move-in evaluation include all required elements was discussed with Staff 1 (Administrator) on 02/16/22. He acknowledged the findings.

C252 OAR 411-054-0034 Resident Move-in and Eval: Resident Evaluation

1. Facility has updated the resident evaluation document and has ensured all required componets are in place, and will be personalized to each resident, including, but not limited to: Spiritual preferences, Mental Health issues, personality, ability to use call system, pain, nutrition, treatments, fall risk and history, complex medication regimen, history of dehydration and or weight loss or gain, recent losses,unsuccessful prior placements, elopement risk or hx, smoking, alcohol and drug use, and enviromental factors.

2. Facility administrator and IDT will review all resident evaluations and service plans, prior to admission , upon admission, 30 days after admission, and  quarterly, and after a significant change of condition to ensure all evaluations are completed appropriately and contain all required components.

3. Facility Administrator and LN will ensure that resident move-in evaluations are completed prior to resident admission and placed in the permanent record.

4. Administrator or Designee will audit all resident records on quarterly schedule to ensure on going compliance. Resident #2, (who was admitted following becoming homeless), evaluation was reviewed and missing components were added where possible.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status and care needs and lacked clear direction to staff for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2021 with a diagnosis of diabetes and chronic pain.

Resident 1's service plan was not reflective and/or lacked clear direction to staff in the following areas:

* Meal assistance;

* Transfer ability;

* Bed mobility;

* Ambulation; and

* Customary routines such as dressing and grooming and bathing.

The need to ensure service plans were reflective of resident's current health status and care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/17/22. They acknowledged the findings.

C 260 OAR 411-054-0036 (1 - 4) Service Plan : General

1.Resident #1 service plan was updated with clear, concise, resident-specific informaion and intervention in the following areas: Meal assistance, Transfer ability, Bed Mobility, Ambulation and Customery routines such as dressing, grooming and bathing. Res #1 has since passed while on hospice.

2. All resident service plans will be audited to ensure service plans are reflective of resident's current health status and care needs and give clear direction to staff.

3. Service plans will be reviewed and audited prior to admission, upon admission, 30 days after admission, quarterly thereafter (per normal schedule of review) or when a resident experiences a significant change of condition.

4. All resident service plans will be audited to ensure that each service plan is personalized with resident specific information, and has clear interventions/instructions for staff to follow.

5. Facility Administrator, Designee and LN will be responsible for overseeing service plan completion.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and monitored to resolution and failed to determine and document actions or interventions and communicate those to staff for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:

1.  Resident 1 was admitted to the facility in 06/2021 with a diagnosis of diabetes, chronic pain and osteoarthritis.

Progress notes dated 12/10/21 through 02/08/22 were reviewed and showed the resident experienced the following changes of condition:

* 11/22/21 - RN identified a bi-lateral yeast infection under both breasts;

* 12/09/21 - Staff transferred Resident 1 to the ER for flu like symptoms;

* 12/21/21 - Return from a hospital stay;

* 01/18/22 - Fall resulting in neck/back pain and sent to ER;

* 01/19/22 - Positive COVID -19 diagnosis;

* 01/22/22 - Return from hospital stay and diagnosed with a UTI; and

* 01/26/22 - Resident was too weak to get out of bed and was now bed bound.

Resident 1 experienced changes of condition that were not evaluated to include development of actions or interventions nor evidence of monitoring through resolution.

2. Resident 2 was admitted to the facility in 12/2021 with a diagnosis of chronic pain. Progress notes dated 12/27/21 through 02/15/22 were reviewed and showed the resident experienced the following changes of condition:

* 12/27/21 - Resident moved into the facility; and

* 01/23/22 - Resident 2 tested positive for COVID - 19.

Resident 2 experienced changes of condition that were not evaluated to include development of actions or interventions nor evidence of monitoring through resolution.

Resident 1 and 2's changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/18/22. They acknowledged the findings.

C 270 OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. The facility LN and Administrator will review short-term changes of conditions and ensure that an appropriate care plan is in place, including but not limited to: Resident evaluation, intervention for staff to follow, and monitoring until resolution.

2. Staff will receive in-service training related to shor-term change of conditions with focus on monitoring through the alert charting process, with appropriate documentaion including ISP/TSP, and when to call the nurse. The facility has implemented a 24hr binder/process, and all staff will be re-inserviced on the 24hr. process.

4. Staff will receive in-service training related to change of condition requirements, including but not limited to: appropriate resident evaluation, appropriate documentaion, and interventions for staff to follow. The facility has implemented a 24hr binder/process, and staff will be re-inserviced on the 24hr process.

3. The facility implemented and added appropriate interventions, for resident #2 and will ensure that staff are made aware of these interventions via ISP/TSP. The facility LN will ensure that residents who experience a change of condition are monitored (care tracking)at least once weekly, until return to baseline or establishment of new baseline. Staff

4. The facility was implementing appropriate interventions for res # 1 who was admitted with diabetes and other health concerns, however the resident passed while being on Hospice. The Administrator, Designee and LN were educated regarding the current Disclosure Statement, which states that at the present time Brookhurst is unable to admit persons who are a two person transfer. If a resident becomes a two person transfer, appropriate interventions are to be put into place.The facility conducted a full audit of all residents currently residing  at Brookhurst and identified that there were not any residents who require two person transfers currently.

4. Facility Administrator, or designee and facility LN will review the 24hr process daily to ensure all change of conditions have appropriate oversite and documentation in place.

Based on interview and record review, it was determined the facility failed to ensure signed physician's orders were kept in the facility for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

Resident 1 and 2's 02/01/22 through 02/15/22 MARs were reviewed and physician's orders were requested on 02/17/22. On 02/17/22 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (RN) reported they did not know signed physician's orders needed to be kept on site and in the resident's medical chart.

There was no documented evidence Resident 1 and 2's medications were being administered as ordered.

The surveyor requested the facility obtain signed physicians orders on 02/17/22. On 02/18/22, the facility obtained signed orders for Resident 1 and 2.

The need to ensure signed physician's orders are kept in the facility was discussed with Staff 1 and Staff 2 on 02/17/22. They acknowledged the findings.

C 303 OAR 411-054-0055 (1) (f-h) Systems: Treatment Orders

1. Staff will be in-serviced relating to following physician's orders, and ensuring that all orders are carried out as prescribed. Staff will be educated on when to notify facility LN and Administrator/Designee when a resident has refused a medication and/or is unavalible.

2. The Administrator or designee will audit the MAR/TAR daily though the medication exception report and 24hr binder daily to ensure all treatments and medications are being carried out as prescribed. Physicans orders will be sent out for review as due.

3. The facility Administrator, LN and or designee will be responsible for ensuring oversight related to physician's orders and making certain that the physicians orders are up to date and processed according to regulations.   

Based on interview and record review, it was determined the facility failed to ensure all pre-service dementia training was completed prior to beginning job duties for 2 of 2 newly hired direct care staff (#s 4 and 6) whose training records were reviewed. Findings include, but are not limited to:

The facility's training records were reviewed on 02/17/22 and revealed Staff 4 and 6 (Caregivers), hired 05/28/21 and 01/13/22 respectively, lacked documented evidence all components of the pre-service dementia training were completed prior to beginning their job duties.

The need to ensure staff completed all components of the pre-service dementia training was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/17/22. No additional information was provided.

C370 OAR 411-054-0070 (3 - 4) Staffing Rqmts and Training: Caregiver Rqmts

1. The facility Administrator will ensure that all new-hires have completed required trainings including pre-service dementia training, prior to beginning job duties, by implementing a training grid for all staff. All new-hires will be assigned the required trainings during new - hire paperwork. Any existing staff that have not completed required trainings by 04/09/2022 will be removed from the schedule.

2. The facility Administrator will audit/review the training grid prior to any employee starting their job duties, as well as, at least weekly to ensure on-going trainings are completed.

3. The facility Administrator and or designee will monitor and provide oversite.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 4 and 6) received training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

The facility's training records were reviewed on 02/17/22 and revealed Staff 4 and 6 (Caregivers), hired 05/28/21 and 01/13/22 respectively, lacked documented evidence of receiving abdominal thrust training within 30 days of hire.

The need to ensure all newly hired staff were trained in abdominal thrust within 30 days of hire was discussed with Staff 1 (Administrator) on 02/17/21. He acknowledged the findings.

C372 OAR 411- 054-0070 (5) (8) Training within 30 days: Direct Care Staff

1. All current employees will be audited to ensure all required trainings are up to date and in compliance. Any employee out of compliance with trainings will be scheduled time to finish trainings. Any employee who has not completed required trainings by 04/09/2022 will be removed from the schedule.

2. Facility Administrator will implement a training grid for all staff members, including pre-service trainings, those required within 30 days of employment, and all on-going trainings. Abdominal Thrust training will be implemented and included on the training grid.

3. Facility Administrator or designee and facility RN will review training grid at least once weekly, and prior to new-hires starting on the floor to ensure that all trainings are complete and that each employee has documented competency in job duties.

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components. Findings include, but are not limited to:

Fire and life safety records for June 2021- January 2022 were reviewed and lacked the following components:

*Number of residents evacuated; and

*Evacuation time period needed for fire drills.

The need to ensure the facility was in compliance with all required fire drill components was discussed with Staff 1 (Administrator) on 02/16/22. He acknowledged the findings.

1.

Written fire drill records will be kept to document fire drills.  Ashley Manor has developed and implemented a new fire drill form as of 03/08/2022 to document fire drills that includes:

A) Date and time of day:

B) Location of simulated fire origin:

C) Escape route used:

D) Problems encountered and

    comments relating to residents who

    resisted or failed to participate in the drills.

E) Evacuation time period needed

F) Staff members on duty and participating and

G) Number of occupants evacuated.

The Administrator and Designee will oversee that Unannounced fire drills will be conducted and recorded every other month at different times of the day, evening and night shifts. Administrator and Designee will audit the fire drill form to make certain that the entire form is completed and that required information and components have been documented. On going training will be provided by the Administrator and Designee for subject of fire drills and record keeping.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

Observations on 02/16/22 showed all exit doors did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

During a tour of the facility on 02/16/22 with Staff 1 (Administrator), he verified exit doors alarms were not operational.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 on 02/17/22. He acknowledged the findings.

1.

Exit door alarms or other acceptable system will be provided for security purposes and to alert staff when residents exit the RCF at all times.  Entry and Exit Door alarms were installed in new or operational condition and new batteries were placed in alarms. The Administrator or Designee will audit the door alarms and make sure that the alarms are in working order daily and will replace batteries as needed.