Brookdale Wilsonville

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 05/01/25 at 11:00 am, the facility kitchen was observed to need cleaning and repair in the following areas:

* Top of dishwashing machine – significant build of debris (food/chemicals) ;

* Dishwashing room caulking on wall of dirty side – significant build up of black matter;

* Commercial stand mixer food guard – food splatters;

* Ice maker vent – build up of dust;

* Top of steamer – dusty;

* Wall behind steamer – grease drips/spills;

* Sides of deep fat fryer – grease drips/spills;

* Ceiling vent above two door refrigerator – significant build up of dust; and

* Shelf containing spices above microwave – dusty/debris.

Other concern:

* Staff with facial hair not using beard restraints.

The areas of concern were observed and discussed with Staff 1 (Dining Service Manager) and discussed with Staff 2 (Executive Director) on 05/01/25. The findings were acknowledged.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted on 11/08/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 11/08/23, conducted 01/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.


The findings of the second revisit to the kitchen inspection of 11/08/23, conducted 03/28/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation and food service on 11/08/23 revealed the following:* There were dirty cupboards and peeling laminate under the beverage station located in the dining room; * The hand washing sink located in the kitchen was in need of caulking and there was brown matter on the wall behind the sink; * There was debris observed on top of the warewashing machine and the wash temperature gage's glass covering was cracked; * All observed cutting boards had deep score marks and were in need of being replaced; * Garbage cans had drips, spills, and debris present; * The dry storage bins located in the front food prep area had brown matter present on the top and in front of each bin; * There was a scoop located inside of the "panko" storage bin; * The sandwich bar prep area's attached cutting board had score marks visible and was in need of replacement; * There was food debris present on the lower shelves and under the hood located in the hot and cold food storage area; * The cold food storage area's cough guard had splatters of debris present; * The sides, front, and top of the stove were observed to have built up food and oil debris; * The inside of the left oven had baked on food spillage present; * The lower shelf on the left side of the stove was observed to have a dried white substance; * Shelving directly above and to the right of the three compartment sink was sticky to the touch; * The outside of the food processor had debris present; * The inside of the microwave was observed to have food splatters inside; * The shelf under the microwave was observed to have dust and debris present and the waffle irons stored on the lower shelf had a built up layer of oil present on each of them; * The inside of the refrigerator located behind the stove was observed to have splatters and food debris located on the bottom and in a tray that was holding condiments; * There were uncovered food items inside of the walk-in cooler; * There were boxes stored on the floor of the walk-in freezer; * The bread cart shelves had dust and debris observed; * A utility cart had built up debris around the outside of the cart and the top shelf had a large crack observed; * The inside of the refrigerator, located in the meal pick up area, had splatters throughout, including inside of the lower drawers; and * There were personal items (e.g. coats, sweaters, a holiday hat, etc.) being stored in a shelving unit. The areas in need of cleaning and repair were reviewed with Staff 2 (Dining Services Director) on 11/08/23. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observations of the kitchen on 01/25/24 identified the following:* The interior/exterior of ovens had a build-up of grease and burnt food debris; * The lower shelf of the mixer table was covered with a grayish-white substance; * Black residue was on and around the ceiling vent above the dishwashing area; * Numerous saute pans and muffin tins were scorched, tarnished, and heavily scratched; and* The base of the food processor was broken. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 2 (Dining Services Director) on 01/25/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.

The findings of the on-site investigation, conducted 09/13/23 through 09/15/23, are documented in this report. The investigation 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a site visit on 09/13/23, it was confirmed the facility falsified records requested by the Department. Findings include, but are not limited to:a.During an interview, 09/13/23, Staff 2 (LPN) stated s/he had given Staff 3 (Med Tech) training documents to sign 10 days prior to the site visit.During an interview, Staff 3 stated Staff 2 had given him/her the training documents to sign that day.The unsigned caregiving training documents were observed and photographed by Complaint Specialist on Staff 3's desk at 12:12 pm.At 2:50 pm the same documents were again reviewed, signed by Staff 3, and backdated to 10/12/22.The above findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 09/15/23.It was determined the facility falsified records requested by the Department.Verbal plan of correction: Training packets to be signed at time of training beginning immediately. LPN and RCC responsible for training. ED will oversee process.b. Based on interview and record review, conducted during a site visit on 09/13/23 and 09/15/23, it was confirmed the facility failed to ensure the accuracy and preservation of records for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:Resident 1 returned to the facility from a nursing facility on 09/20/22. The facility was unable to provide the discharge orders from the nursing facility when requested by the Department.Resident 1's MAR, dated 9/01/22 through 10/31/22, indicated s/he did not receive Lasix from 09/20/23 until 10/28/22.A transcription of a phone call, dated 10/25/22, from Resident 1's PCP indicated Staff 8 (MT) stated Resident 1 "is receiving [Lasix] daily".Progress notes for Resident 1, dated 10/26/22, indicated Staff 2 (LPN) " Questioned as to why [s/he] was no longer on Lasix. Upon investigation found orders in chart that were not processed appropriately. Sent [prescription] to pharmacy and started Lasix, notified PCP via voicemail as well as fax. "The facility was unable to provide the fax to Resident 1's PCP on 10/26/23 when requested by the Department.Progress notes for Resident 1, dated 10/28/22, indicated the facility received Resident 1's Lasix on 10/28/22.During an interview, 09/15/23, Staff 2 stated "started Lasix" as written on Resident 1's progress notes "meant" that the process to acquire and administer Resident 1's medication had begun.The above findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 09/15/23.It was determined the facility failed to ensure accuracy and preservation of resident records.Verbal plan of correction: LPN and RCC to review chart notes and double check one another's work to ensure accuracy. ED to review daily reports in progress notes, alerts and documentation and pass it on to LPN. Daily clinical meetings to begin immediately with LPN/RCC/ED on alert charting.

Based on interview and record review, conducted during a site visit on 09/13/23 and 09/15/23, it was confirmed the facility failed to provide sufficient care staff to meet the scheduled and unscheduled needs of residents. Findings include, but are not limited to:A review of the facility's staffing plan indicated there was to be one caregiver and one med tech on shift for day, swing, and night shift. A review of staff time sheets, 01/23/23-01/30/23, indicated:- One direct care staff worked 01/23/23 swing shift.- One direct care staff worked 01/24/23 swing shift.- No direct care staff worked 01/25/23 swing shift.- One direct care staff worked 01/25/23 night shift.- One direct care staff worked 01/26/23 swing shift.- One direct care staff worked 01/27/23 swing shift.- No direct care staff worked 01/28/23 day shift.- No direct care staff worked 01/28/23 swing shift.- One direct care staff worked 01/29/23 day shift.- One direct care staff worked 01/29/23 swing shift.- One direct care staff worked 01/30/23 swing shift.During an interview, 09/15/23, Staff 2 (LPN) stated s/he had worked 80+ hour weeks over that period covering shifts. The facility was unable to provide a record of Staff 2 working in the capacity of direct-care staff as opposed to an ancillary staff member.During an interview, 09/13/23, Staff 3 (Med Tech) stated staffing had been an issue "around 9 months ago".Call light records were unable to be reviewed for that period as the facility had since replaced their call light system and the previous one had been removed.Resident 1 was unable to be interviewed as s/he is no longer residing in the facility.The above findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 09/15/23.It was determined the facility failed to provide sufficient care staff to meet the scheduled and unscheduled needs of residents. Verbal plan of correction: Facility has replaced direct care staff who have quit, are currently fully staffed and are currently interviewing to replace staff who have recently given notice. Facility now has an RCC who is able to fill the role of direct-care staff in the event of an absence. Facility will no longer count ancillary staff as direct-care staff.

Based on interview and record review, conducted during a site visit on 09/13/23 and 09/15/23, it was confirmed the facility failed to have a training program that includes methods to determine competency of direct care for 2 of 3 sampled staff (#s 5 and 6). Findings include, but are not limited to:During an interview, 09/13/23, Staff 3 (Med Tech) stated training procedures had drastically changed since s/he started working for the facility, and due to high turnover caregivers and med techs were regularly expected to perform the full duties of their job within a few days of being hired.The facility was unable to provide competency checklists for Staff 5 (Med Tech) and Staff 6 (Caregiver).The above findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 09/13/23.It was determined the facility failed to determine competency of direct care when training staff.Verbal plan of correction: Facility to immediately begin an audit of staff training records and re-train staff as necessary. Audit has begun as of 09/15/23.

Based on observation and interview, conducted during a site visit on 09/13/23, it was confirmed the facility failed to keep interior surfaces in good repair for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:On 09/13/23 a hole approximately six to eight inches across was observed in Resident 3's drywall where the interior doorknob at the entrance to the unit had impacted the wall. Additionally, there were scratches and gouges throughout the apartment at levels where Resident 3's electric wheelchair had impacted surfaces.During an interview, 09/13/23, Resident 3 stated the hole had been there for some time because s/he had trouble controlling his/her electric wheelchair. S/he stated maintenance had been notified and that s/he had expressed a desire for installation of a method to stop or slow the door from shutting.During an interview, 09/13/23, Staff 2 (LPN) confirmed the hole in Resident 3's wall had been present for a while, and further stated it hadn't been fixed because Resident 3 would slam the door into the wall again anyway.During an interview, 09/13/23, Staff 1 (Executive Director) stated the facility's maintenance person had been terminated the morning of 09/13/23.The above findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 09/13/23 and 09/15/23.It was determined the facility to keep interior surfaces in good repair.Verbal plan of correction: Facility to fix the walls of resident's apartment within 30 days of 09/13/23.

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



The findings of the 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 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 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 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 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 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.
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.

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. 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.
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.

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 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 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 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.
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.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 12/20/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the kitchen inspection, conducted on 09/28/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 09/28/22, conducted 12/01/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in accordance with the Food Sanitation Rules OAR 333-150-0000. Finding include, but are not limited:On 09/28/22 at 10:50 am, the kitchen was observed to need cleaning in the following areas:* The outsides and covers of large food bins containing oatmeal, flour, sugar and panko had food debris, drips and splatters;* The top and sides of the dish washer had drips/splatters and food debris. The dish rack shelf had dust/food debris;* The wall behind an unused steam jacketed kettle had drips, splatters and the shelf it was sitting on had an accumulation of food debris/drips/black matter;* Shelves below the steam table had food drips/debris;* The front and sides of the stove/oven had significant accumulation of dried on food drips and splatter; * The vents in hood above the stove top had accumulation of dust and grease and the outer side vents of the hood had built up dust;* The fronts of three serving utensil drawers had food drips/splatter; and* The plate warmer had food drips/splatter.Other areas of concern included:* Individual servings of ice cream in the walk in freezer were not labeled/dated;* The reach in refrigerator had trays of fruit and shredded cheese without labels/dates;* The sandwich bar refrigerator had containers of fruit and green salad not labeled/dated;* Large food bins containing oatmeal, flour, sugar and panko had scoops in the product;* Small container of brown sugar on a prep counter had a spoon in it; and* Three garbage cans not actively being used were uncovered in the prep area, steam table area and in the dish washing room.The above concerns were observed and discussed with Staff 1 (Executive Director) and Staff 2 (Cook) on 09/28/22. The findings were acknowledged.