Pacific Living Centers of Medford at Brookhurst.

“Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely, which documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (# 1) who experienced significant changes of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 11/05/24 service plan, 08/06/24 through 11/06/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident had severe but intermittent behaviors. The resident was difficult to redirect and frequently required police and/or EMT assistance along with emergency room transport before s/he would calm. The resident was able to eat independently with minimal cues from staff. The resident was able to make some needs known depending on his/her mood and any behaviors. Observations on 11/06/24 were limited as the resident had significant behaviors in the morning, meal items and dishes were thrown around the unit by the resident. The resident was transported to the hospital for evaluation. The resident returned the same evening. Multiple observations of the resident on 11/07/24 showed the resident in and out of his/her room throughout the day. The resident came and went on his/her own the majority of the time. The resident was reminded/assisted to meals and ate independently once served. The resident was provided fluids and snacks in between meals when s/he would accept. Weight records for 08/2024 through 10/2024 showed the following: * An 8.8-pound weight gain between 08/01/2024 and 09/03/24, which constituted a 5.45% gain in one month; and * A 3.21-pound weight loss between 09/03/24 and 10/01/24, which constituted a 7.76% weight loss in one month. The resident’s weight fluctuated up/down one to two pounds in the remainder of October 2024. The resident weighed 157.3 on 10/24/24, a less than one pound change from the 10/01/24 weight. The resident was not officially interviewed due to behavior concerns and a fresh return to the facility. S/he did indicate a love of soda. In interviews conducted between 11/06/24 and 11/07/24, the following was noted: Staff 3 (CG/MT), Staff 8 (CG) and Staff 10 (CG) indicated the resident was independent with meals. The resident was easily irritated and would become agitated without a lot of warning. The staff indicated behaviors did not only occur at meals. Staff 3 and 8 stated when the resident began to escalate there was not much that would calm the situation, but they would try food/fluids among other items. The staff further indicated the resident sometimes slept through the meals and they would offer alternates or shakes when s/he was awake. The facility RN was not available for interview. Staff 1 (Interim ED) was unable to locate any RN assessment completed related to the September 2024 or October 2024 significant weight changes. The facility failed to ensure an RN assessment was completed timely for a severe weight gain and a subsequent severe weight loss. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 and Staff 2 (Interim Assistant ED) on 11/06/24 and 11/07/24. The staff acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness and weekly progress documented until resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure resident care minutes were entered accurately in the ABST. The inaccurate entries related to required resident care times created potential inaccuracies in the required number of staff to complete the care on all shifts. Findings include, but are not limited to: Review of the facilities ABST entries, staff schedule, calculated staffing hours and posted staffing plan were completed and showed the following: * Observations of resident care and interviews with staff indicated the current ADL needs for multiple sampled residents were not reflective in the ABST, including an accurate amount of staff time needed to provide care. * Staff working on the floor matched the posted staffing plan, but the ABST did not contain all required minutes, for all care needs on all shifts. Due to inaccuracies the facility was unable to show staffing numbers exceeded the staffing time calculated by the ABST. The need to ensure all residents were accurately entered in the ABST and that the facility staffing plan and staff working on the floor, exceeded ABST staffing calculations was discussed with Staff 1 (Interim ED) and Staff 2 (Interim Assistant ED) on 11/06/24 and 11/07/24. The staff acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code, fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 05/2024 and 10/2024, showed fire drill documentation was lacking in the following areas: * The escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; and * The number of occupants evacuated. The fire drills were not completed at least every other month on alternating shifts. Additionally, the records reviewed did not show life safety training was provided on alternating months from the fire drills. The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training, was discussed with Staff 1 (Interim ED) and Staff 2 (Interim Assistant ED) on 11/06/24 and 11/07/24. The staff acknowledged the findings.”

“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: Refer to C270 and C513. 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 observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility on 11/06/24 and 11/07/24 showed the following areas in need of cleaning or repair: * Multiple walls and baseboards near the dining room and living room had spills, debris and/or black accumulation at the edges; * Windowsills had dirt, debris and dead insects along the inner edges; * Caulking around the toilets in the shower room and weight room/staff bathroom was discolored and/or missing; * Several handrails had chips, dings and small chunks missing from the surfaces; * Multiple pieces of furniture in the living room had dark stains or spills on the arms and/or seats. One recliner chair had a large rip at the top of the chair with exposed stuffing; * Room 2 had multiple scratches and gouges to the laminate flooring. The caulking in the bathroom, around the toilet was discolored or missing in several spots; * Shower room had multiple cracked tiles and scrapes to the wall; * Room 7 had multiple scrapes and scuffs to the floor, the toilet seat was covered with a brown splattered substance. Caulking around the toilet was discolored or missing in several spots and a thick, light brown substance was accumulated around the base of the toilet; * A large dark stain was noted to the carpet in the living room nearest to room 7; and * A bed cane located in room 7 bed A, was wrapped with black duct tape which was frayed. The padding underneath the tape appeared to be torn and/or missing pieces. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Interim ED), Staff 11 (Regional Director of Operations) and Staff 12 (Maintenance) on 11/06/24 and 11/07/24. The staff acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C362, C420 and C513. Refer to C362,C420 and C513 OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Referral for C513 OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270 and C280. Refer to C270 and C280. OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Referral for C270. OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height and constructed to reduce the risk of elopement. Findings include, but are not limited to: A tour of the facility's memory care courtyard on 11/06/24, showed an approximate six-foot-wide section of fence was less than was less than six feet in height. The section of fencing was located at the back of the courtyard in the grass/bark dust section. The height of the fencing ranged from 5 ft 8 inches to 5 ft 10 inches in height. One resident was observed outside without staff during the survey. The resident stayed in the concrete area and did not approach the grassy area. The fencing sections that were less than six feet in height were shown to and discussed with Staff 1 (Interim ED), Staff 11 (Regional Director of Operations) and Staff 12 (Maintenance) on 11/06/24 and 11/07/24. They acknowledged the findings.”

“Based on observation, interview, and record review, 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 10/22/24 revealed: * Splatters, spills, drips, and debris noted on: - Counters; - Interior of cupboards; - Interior of the oven; - Interior of drawers; and - Flooring in dry storage/pantry closet. * There were no disposable towels available for hand washing. Staff were observed to use a soiled dish towel to dry hands. * Damage to the interior of cupboards creating porous un-cleanable surfaces. * Damage and soiled carpet in the food storage pantry. * No documented evidence temperatures of cooked food consistently monitored to ensure proper cooking. * No documented evidence temperatures of refrigerators were monitored. * Undated and unlabeled foods were noted in the refrigerator. * Staff observed to not change gloves between tasks, touching ready to eat foods. * Caregiving Staff serving meals, who provided incontinent care to residents, did not use an apron while handling food. *Plates of food delivered to resident rooms were not covered. * Residential dishwasher were used to clean the dishes. Staff used the “1 Hour” express cycle, resulting in un-sanitized dishes. The food handling and storage concerns, and areas in need of cleaning and repair, were reviewed with Staff 1 (Interim Executive Director) on 10/22/24. She acknowledged the findings.”

“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: Brookhurst has implemented the following below.”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240. Refer to C 240. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: see C 240 OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“The findings of the kitchen inspection, conducted 12/28/23, 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. The findings of the kitchen inspection, conducted 12/28/23, 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.”