Brookdale Mt Hood

Survey KIT004911

3 Deficiencies

Date: 6/9/2025

Type: Kitchen

Citations: 3

Citation #1: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:

t Visit: 6/9/2025 | Not Corrected

1 Visit: 8/20/2025 | Not Corrected

Regulation:

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).

Inspection Findings:

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

The facility's kitchen was toured on 06/09/25 at 9:52 am.

a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust, garbage, or black matter was observed on, in or underneath the following:

* Baseboards and flooring throughout the kitchen;
* Walls throughout the kitchen;
* Counters throughout the kitchen;
* Lighting fixtures throughout the kitchen;
* Open shelving under drink stations;
* Microwaves;
* Toaster;
* Sandwich press;
* Interior casing of can opener;
* Shelving under steam table;
* Sides of grill and equipment surrounding grill;
* Interior of drawers;
* Baker's racks;
* Flooring of walk-in refrigerator;
* Exhaust fan grates and ceiling in walk-in refrigerator; and
* Warewasher, including plumbing and mechanics.

b. The following kitchen items required repair or replacement:

* Coffee station shelving had cracks, gouges and bare wood exposed;
* Exposed area in baseboard under coffee station;
* Tea and cocoa station shelving was missing laminate with bare wood exposed;
* Microwave interior had peeling enamel;
* Green cutting board had gouges and scrapes;
* Sandwich press had peeling enamel;
* Corner drywall near freezer was gouged with metal corner guard exposed; and
* Tile near warewasher was gouged.

c. Observation of the facility's refrigerators and dry storage revealed multiple food items were not covered, dated, and/or labeled appropriately.

d. Poor infection control practices observed, but not limited to:

* Plastic cups, used as scoops, were stored in the containers with the food products;
* Stand mixer and mixing bowl were left uncovered when not in use;
* Sanitizing buckets had cold water, and kitchen staff were not using chemical testing strips;
* Rotten potatoes, moldy blackberries, and wilted greens were observed stored in fresh produce;
* Kitchen staff failed to perform hand hygiene consistently between dirty and clean tasks; and
* The warewasher was not reaching the required temperature of 120 degrees F.

Concerns regarding the warewasher not reaching the minimum temperature for sanitation were discussed with Staff 1 (ED) on 06/09/25 at 11:47 am. The temperature was immediately adjusted and was re-tested at 123 degrees F.

A kitchen walkthrough was completed with Staff 1 and Staff 2 (Cook/Dishwasher) on 06/09/25 at 1:51 pm. The areas that did not meet the rules, were discussed with Staff 1 and Staff 2. They acknowledged the findings.

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:
Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

The facility's kitchen was toured on 08/20/25 at 9:00 am.

a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust, garbage, or black matter was observed on, in, or underneath the following:

* Tile flooring/grout lines/cove base at kitchen entrance and throughout the kitchen;
* Metal edge of hand wash sink and white half wall adjacent to coffee area;
* Caulking behind hand wash sink;
* Floor drain near ice machine;
* Multiple walls throughout the kitchen;
* Open shelving and bins under drink stations;
* Microwave at tea/cocoa station;
* Shelving under steam table;
* Sides of grill and equipment surrounding grill;
* Baker's racks;
* Flooring of walk-in refrigerator;
* Exhaust fan grates and ceiling in walk-in refrigerator; and
* Caulking and wall underneath dish machine.

b. The following kitchen items required repair or replacement:

* Baseboard under coffee station;
* Tea and cocoa station shelving had laminate taped to the edge;
* Corner drywall near freezer was gouged, with metal corner guard exposed;
* Tile near dish machine was gouged;
* Paint on entry/exit doors was scratched; and
* Scraped/gouged wall behind food bins.

c. Two kitchen staff did not have facial hair contained/covered.

A kitchen walk-through was completed with Staff 1 (Executive Director) on 08/20/25 at 10:15 am. She acknowledged the findings.

Plan of Correction:

1.All identified areas in the kitchen were thoroughly cleaned in the days following the inspection. This included removal of food debris, spills, grease, and dust from the following areas:
• Baseboards and flooring throughout the kitchen
• Walls throughout the kitchen
• Counters throughout the kitchen
• Lighting fixtures throughout the kitchen
• Open shelving under drink stations
• Microwaves
• Toaster
• Sandwich press
• Interior casing of can opener
• Shelving under steam table
• Sides of grill and equipment surrounding grill
• Interior of drawers
• Baker’s racks
• Flooring of walk-in refrigerator
• Exhaust fan grates and ceiling in walk-in refrigerator
The microwave and sandwich press were removed and replaced with new equipment. Damaged cutting boards were discarded and replaced. The drink station, which includes shelving with cracks, gouges, and exposed wood, is currently pending replacement and a vendor quote is being obtained. Other damaged areas, including gouged tile and drywall, are being assessed for appropriate repair or resurfacing.
All improperly stored, uncovered, or unlabeled food items were discarded at the time of the inspection.
Plastic cups that had been used as scoops were immediately removed and discarded. Staff were re-educated on infection control expectations, including proper hand hygiene when transitioning between dirty and clean tasks. The stand mixer now has a cover in place, and staff were instructed to keep it covered at all times when not in use. Sanitizing buckets were found to be filled with cold water and not tested for chemical strength. Staff were re-educated on correct sanitizing procedures, including maintaining temperature and testing with chemical strips, which were available but not being utilized. Spoiled produce—including blackberries, potatoes, and wilted greens—was discarded. The warewasher was found to be operating below the required sanitation temperature; the water heater was adjusted during the inspection and the warewasher was confirmed to be reaching 120°F.
2. A full inspection of the kitchen and food service areas will be completed prior to the plan of correction compliance date to ensure no other deficient practices exist beyond those identified during the survey. Any additional findings will be addressed and corrected at that time.
Although no other staff were cited for infection control concerns, a monthly kitchen staff meeting has been scheduled on an ongoing basis to review sanitation expectations, address any concerns, and reinforce key food safety and infection control policies.
As an added layer of oversight, the facility has updated its cleaning checklists and implemented a structured walkthrough schedule: daily walkthroughs by the cook on duty, weekly walkthroughs by the lead cook/dining services coordinator/designee, and monthly walkthroughs by the Executive Director/designee—or more often if concerns arise.
3. Daily, weekly, monthly and as needed for concerns.
4. Cooks, Lead Cook, Dining Services Coordinator, Executive Director, or Designees1. The kitchen flooring, including tile, grout lines, cove base, and walk-in refrigerator floors, was steam cleaned and power washed, with regular steaming added to the cleaning schedule. The metal edge of the hand wash sink and adjacent half wall were thoroughly cleaned. Caulking behind the hand wash sink was cleaned, and sections that could not be adequately sanitized were replaced. Floor drains near the ice machine were fully cleaned. All walls, open shelving, bins, the microwave, shelving under the steam table, grill sides and surrounding equipment, and baker’s racks were cleaned and sanitized. Exhaust fan grates and the ceiling in the walk-in refrigerator were dusted and cleaned. The caulking and wall underneath the dish machine were cleaned, with replacement performed where cleaning was not sufficient.
The coffee, tea, and cocoa station was scheduled to be resurfaced, and the area underneath was enclosed to ensure smooth and cleanable surfaces. Drywall near the freezer was patched and repainted, restoring the integrity of the wall. Gouged tile near the dish machine was repaired. Scratched paint on the entry and exit doors was touched up, and scraped walls behind the food bins were patched and painted to create intact and easily sanitized surfaces.
Beard nets were purchased and distributed to all kitchen staff, and all staff received immediate re-education on personal hygiene requirements and food sanitation standards. Supervisory spot checks were initiated to verify compliance with facial hair covering at the beginning of each shift.

2. To correct the system and prevent future violations, the facility has implemented comprehensive cleaning checklists that address each specific area cited, including floors, grout, drains, walls, shelving, equipment surfaces, and refrigeration units. These checklists are divided into daily, weekly, and monthly tasks to ensure consistent attention to both high-use and hard-to-reach areas. All cleaning is logged by staff and reviewed by supervisory personnel for accountability. In addition, a preventive maintenance program has been established to identify and promptly repair damaged or uncleanable surfaces such as drywall, tile, paint, and shelving. Staff hygiene compliance is now monitored through mandatory beard net use, reinforced by staff education, updated dress code policy, and supervisory spot checks at the start of each shift. These system corrections create multiple layers of oversight to maintain sanitation, ensure repairs are completed in a timely manner, and sustain compliance with food sanitation rules.

3. The Executive Director, Dining Services Coorintator, or designee will complete a kitchen walk-through each week to verify that cleaning, maintenance, and staff compliance are sustained.

4. Executive Director, Dining Services Coordinator, or Designee

Citation #2: C0370 - Staffing Requirements and Training – Pre-service

Visit History:

t Visit: 6/9/2025 | Not Corrected

1 Visit: 8/20/2025 | Not Corrected

Regulation:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding:

(a) A review of their written position description with their job responsibilities.

(b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings.
(A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities.
(B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of
this rule.

(c) Abuse and reporting requirements.
(d) Fire safety and emergency procedures.

(e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease.

(A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:
(i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease.
(ii) Policy addressing respiratory hygiene and coughing etiquette.
(iii) Standard precautions.
(iv) Hand hygiene.
(v) Use of personal protective equipment.
(vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection.
(vii) Isolating and cohorting of residents during a disease outbreak.
(viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks
under ORS 433.004 and safeguards for employees who report disease outbreaks.

(B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.
(i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.
(ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.

(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below:
(A) Effective March 31, 2024, all staff must have completed the required training.
(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities.
(g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate.

(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.
(a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(A) Documentation of dementia training:
(i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training.
Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.
(ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.
(B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training.
(C) A certificate of completion must be made available to the Department upon request.
(D) Pre-service dementia care training must include the following subject areas:
(i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.
(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.
(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.
(iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:
(I) Identify and address pain.
(II) Provide food and fluids.
(III) Prevent wandering and elopement.
(IV) Use a person-centered approach.

(b) ORIENTATION TO RESIDENT. Pre-service orientation to resident:
(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan.
(B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Inspection Findings:

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 staff (#s 2 and 4) who prepared food had active food handler's certificates. Findings include, but are not limited to:

On 06/09/25, employee records were requested and reviewed to ensure staff had active food handler's cards. The food handler's cards for Staff 2 (Cook/Dishwasher) and Staff 4 (Cook/Dishwasher) were dated as obtained the day of survey. On 06/09/25 at 2:31 pm, the surveyor requested to review Staff 2 and Staff 4’s previous food handler's cards. Staff 1 (ED) reported she “couldn’t track them down.”

The need to ensure staff who prepared food had active food handler’s certificates was discussed with Staff 1 on 06/09/25 at 2:31 pm. She acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding:

(a) A review of their written position description with their job responsibilities.

(b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings.
(A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities.
(B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of
this rule.

(c) Abuse and reporting requirements.
(d) Fire safety and emergency procedures.

(e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease.

(A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:
(i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease.
(ii) Policy addressing respiratory hygiene and coughing etiquette.
(iii) Standard precautions.
(iv) Hand hygiene.
(v) Use of personal protective equipment.
(vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection.
(vii) Isolating and cohorting of residents during a disease outbreak.
(viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks
under ORS 433.004 and safeguards for employees who report disease outbreaks.

(B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.
(i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.
(ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.

(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below:
(A) Effective March 31, 2024, all staff must have completed the required training.
(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities.
(g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate.

(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.
(a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(A) Documentation of dementia training:
(i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training.
Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.
(ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.
(B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training.
(C) A certificate of completion must be made available to the Department upon request.
(D) Pre-service dementia care training must include the following subject areas:
(i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.
(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.
(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.
(iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:
(I) Identify and address pain.
(II) Provide food and fluids.
(III) Prevent wandering and elopement.
(IV) Use a person-centered approach.

(b) ORIENTATION TO RESIDENT. Pre-service orientation to resident:
(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan.
(B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

This Rule is not met as evidenced by:

Plan of Correction:

1. All food service employees have obtained current food handler certifications. The Business Office Coordinator (BOC) is now responsible for tracking food handler card documentation and monitoring expiration dates. Staff will be notified in advance of any upcoming expirations to ensure continuous compliance. Certification records will be stored in the Training Binders located in the business office. Moving forward, food handler certification will be required as part of the onboarding process for all new food service employees. The BOC will review the training tracker at least twice per month to confirm that all required documentation remains up to date.
2. To ensure that no additional staff were out of compliance, a full audit of employee files was completed, and all food service staff were confirmed to have valid food handler certifications. All current documentation is now stored centrally in the Training Binders and monitored by the Business Office Coordinator to prevent future lapses.
3. Twice monthly review of the Training Tracker for food handler's cards expiring and as needed for new hires by Business Office Coordinator. Executive Director will verify at least quarterly to ensure tracker is up-to-date and compliant.
4. Business Office Coordinator and Executive Director

Citation #3: C0455 - Inspections and Investigation: Insp Interval

Visit History:

1 Visit: 8/20/2025 | Not Corrected

Regulation:

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.

Inspection Findings:

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

Refer to C 240.

Plan of Correction:

1. The facility immediately conducted a full kitchen deep cleaning and verified that all previously cited areas were corrected. Staff were re-educated on their responsibilities under the plan of correction, and updated cleaning and maintenance checklists were implemented. A new plan of correction was written to address all cited issues and ensure regulatory compliance.

2.The facility re-educated staff to ensure the kitchen plan of correction is fully implemented and maintained. Cleaning and maintenance tasks from the POC have been built into daily, weekly, and monthly checklists, with documentation reviewed by the Dining Services Manager and oversight by the Executive Director.

3. The Executive Director, Dining Services Coorintator, or designee will complete a kitchen walk-through each week to verify that cleaning, maintenance, and staff compliance are sustained.

4. Executive Director

Survey 6D5Q

1 Deficiencies

Date: 3/14/2024

Type: State Licensure, Other

Citations: 2

Citation #1: C0000 - Comment

Visit History:

1 Visit: 3/14/2024 | Not Corrected

2 Visit: 5/16/2024 | Not Corrected

Inspection Findings:

The findings of the kitchen inspection, conducted 03/14/24, 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 Sanitation Rules OARS 333-150-0000.
The findings of the revisit to the kitchen inspection of 03/14/24, conducted 05/16/24, 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.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:

1 Visit: 3/14/2024 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 5/13/2024

Inspection Findings:

Based on observation, interview, and record review, it was determined the facility failed to ensure proper food preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:The facility kitchen was toured on 03/14/24 at 10:37 am. a. The following areas needed cleaning and/or repair:* Kitchen entrance door leading to the dining room had peeling paint;* There was multiple small holes in the wall by the juice/coffee counter and sink;* Laminate veneer on the bottom and corners of the juice/coffee counter were missing with exposed wood, which created an uncleanable surface;* Coffee cups and other glassware housed in the cabinet beneath the juice/coffee counter were not stored in a manner to prevent cross contamination and the clean dishes were observed to have spillage from coffee and/ or juice;* The juice machine had sticky residue buildup on the nozzles and exterior of the machine;* The handwashing sink between the ice machine and juice machine failed to have splash guards;* The window sill at the kitchen entrance had exposed wood rendering the surface uncleanable;* White three drawer plastic bins to the left of the entrance door (that housed single use food items) were visibly dirty on the interior and exterior;* The ice machine had a brown substance buildup around the interior seal and interior electrical cables;* The floor underneath and behind the upright beverage refrigerator, behind the ice machine and Hobart mixer had a build up of food debris and dust;* The spice rack and spice jars hanging on the wall next to the Hobart mixer were visibly dirty and jars were left open to air;* Galaxy conveyor toaster on the steam table was not cleaned and sanitized after use;* The electrical outlet on the steam table was burned out and in need of repair;* The back of the equipment, wall and floor underneath and behind the Vulcan ovens had a build up of food debris and grease;* The legs of the stand holding the Cleveland steamer had buildup of debris and oxidation;* The counter mounted can opener housing and blade had a buildup of food debris;* A large white wire rack hanging on the wall (to left of the steam table) had multiple areas of protective coating that had peeled off and was rusting;* The electrical power strip in the dry food storage area (shared space with managers office) was burned out and need of replacement; * The floor and shelving in the dry food storage area had a build up of food debris, dust and food was housed with personal belongings such as shoes, clothing and purses;* The reach-in freezers had spillage and food debris buildup on the interior shelves and the exterior front and door handles;* Prep table next to the walk-in refrigerator was pulled off the wall bracket and the caulking between the table and wall was missing;* Spice jars on the shelf above the prep table (next to the walk-in refrigerator) were left open to air and were visibly dirty and the black microwave had food debris buildup on the interior;* Walk-in refrigerator door paint on the exterior and interior was peeling off, the door handle was broken and the door was unable to securely close, and the door's gasket surrounding the door was coming off;* The floor and walls of the walk-in refrigerator had a build up of food debris, splatters and an unknown liquid substance;* The caulk adjoining the stainless-steel ware washing area and the wall above and beneath the warewash area had a buildup of black and brown matter and the caulk was deteriorating which caused water to saturate the wall beneath the ware wash counter;* There was a broken drainpipe in the dishwashing area;* A wire rack in the dishwashing area that housed cleaning chemicals was rusted;* A stainless-steel cart in the dishwashing area had areas of rust, including rust on the casters; and* Approximately 12-inch X 12-inch square floor tiles were missing on the floor underneath the sprayer sink in the dishwashing area; and * Multiple food service racks (stainless steel and plastic) had a buildup of debris and were not sanitized prior to use.Observations of food storage identified the following:*The dry food storage area had multiple packages that were left opened to air and items removed from the original packaging that were left open to air without a label or date (jasmine rice, table salt, split peas, various grains etc.);* The walk-in refrigerator had expired produce (multiple heads of lettuce, onions etc.); and* Fish was improperly stored above and next to butter and eggs.Observations of the food preparation and food service identified the following:* Cold food items (milk-based products, fresh cut vegetables, ready to eat meats and cheeses) plated for food service had temperatures above 41 degrees F. when served from the tray line; and* Approximately 22 blocks of butter that contained soy and milk product was stored on a shelf and not maintained below 41 degrees F.Review of infection control practices identified the following:* Staff 1 (Dining Services Coordinator) failed to ensure hair was effectively restrained;* Staff 1, Staff 2 (Cook) and Staff 5 (Dishwasher) failed to have valid Oregon Food Handler cards; * Multiple kitchen staff and direct care staff observed during meal service failed to consistently perform hand hygiene and change gloves between tasks; * Direct care staff assisting during meal service failed to consistently use aprons;* Staff were observed using the eyewash station as a hand washing station;* Staff failed to have and use test strips for testing sanitation buckets used for sanitizing surfaces and failed to change the sanitation buckets at least every two hours or when the water was visibly dirty; and* Trash cans, including compost bins and a recycling bin with food containers that contained food debris lacked covers when not in use.The kitchen was toured, and the above areas were discussed with Staff 1 and Witness 1 (RN Consultant) on 03/14/24 at 1:32 pm. They acknowledged the findings.

Plan of Correction:

1. Kitchen doors were painted. Holes in wall behind juice/coffee counter and sink will be patched and wall will be painted. Counter holding the juice and coffee maker will be replaced. Temporary covers for the glassware in place, with permanent covers to be installed with new counter.Juice machine was cleaned including cleansing the nozzles and exterior of the machines. Splash gaurds for handwashing sink will be installed. Windowsill at kitchen entrance will be repainted. White three drawer plastic bins were cleaned, both interior and exterior. Ice machine was cleaned. Floors will be deep cleaned throughout the kitchen. Spice rack was cleaned, all spice jars were cleaned, and all spices will be covered. Toaster was cleaned and sanitized. Electrical outlet on the steam table will be replaced. Vulcan overs will be deep cleaned including the back of the machine, the wall, and the floor underneath the ovens. Legs of the steamer stand were cleaned. Can opener was cleaned. Wire rack to left of steam table will be replaced/repaired. Power strip in the food storage office was replaced. Dry food storage area was deep cleaned, including the floors and the racks. Personal items were removed from food shelving. Reach in freezers were cleaned, both interior and exterior. Prep table next to walk in was pushed back against wall and chaulking replaced. Food removed from microwave and disposed of. Walk in walls painted and floors cleaned. Walk in door will be repaired or replaced. Chaulking around dishwashing area was replaced. Drainpipe in dishwashing area will be replaced or repaired. Wire rack in the dishwashing area will be replaced or repaired. Rust removed from the stainless steel dishcart and casters replaced. Tile will be replaced in dishwashing area. All food service racks cleaned. Dry stored foods will be stored in containers with lids with open dates and labels. Expired food removed from walk-in and food arranged properly on shelves. Cold food items will be stored in the walk-in and only removed when it is time to serve them. Butter will be stored in refrigerated unit. Properly fitting hair nets were obtained. Re-education will be provided to all staff regarding hand hygiene, gloves, aprons, and hair nets by 4/25/24. All kitchen staff will maintain current food handlers cards. Soap dispenser and papertowel dispenser will be removed from eyewash station to prevent it from being used as a handwash station. Test strips will be used for testing sanitation bucks at least every two hours. Trash cans, recycling, and food bins will all have covers when not in use. 2. ED and dietary director to distribute daily, weekly, monthly cleaning checklist. Daily walk through by dietary director, ED, or designee. 3. Dietary director or designee will review checklists daily. ED will also do a daily walkthrough of the kitchen until all is in compliance, then weekly walk throughs. ED to review survey checklist with dietary director during 1:1 weekly meeting. 4. Dietary director and Executive director are responsible for meeting and mainting compliance.

Survey 3XKJ

21 Deficiencies

Date: 10/16/2023

Type: Validation, Re-Licensure

Citations: 22

Citation #7: C0252 - Resident Move-In and Eval: Res Evaluation

Visit History:

1 Visit: 10/19/2023 | Not Corrected

2 Visit: 2/1/2024 | Not Corrected

3 Visit: 5/29/2024 | Corrected: 4/16/2024

Inspection Findings:

Resident 1 was admitted to the facility in 10/2023 with diagnoses including Type 2 diabetes and a seizure disorder. The facility used an "Addendum Questionnaire" and a "Personal Service Assessment" document to evaluate residents prior to admitting to the facility. The resident's documents, dated 09/28/23, were reviewed and lacked the following required elements:* Customary routines including eating; * List of current diagnoses; * List of medications and PRN use; * Visits to health practitioner(s), ER, hospital or Nursing Facility in the past year; * Mental health issues including effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * Ability to use call system; * Housework and laundry; * Pain including non-pharmaceutical interventions and how a person expresses pain or discomfort; * Emergency evacuation ability; * History of dehydration or unexplained weight loss or gain; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature. On 10/16/23 at 3:13 pm, Staff 1 (ED) confirmed there was no additional information relating to Resident 1's move-in evaluation. The need to ensure newly admitted resident evaluations included each required element was discussed with Staff 1 and Staff 2 (Health and Wellness Director) on 10/18/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure the move-in evaluation contained all required elements for 1 of 1 sampled resident (# 1) whose evaluation was reviewed. Findings include, but are not limited to:

Based on observation, interview, and record review, it was determined the facility failed to evaluate and gather data that was relevant to the needs and current condition of the resident following a significant change of condition, and ensure the evaluation was used as the basis of the resident's service plan for 1 of 4 sampled residents (#9) whose evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 9 was admitted to the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease and Type 2 diabetes mellitus. During the acuity interview on 01/29/24 it was reported the resident was admitted to hospice.Observations, interviews with staff, and review of the most recent evaluation and service plan dated 01/12/24, identified the evaluation wasn't reflective of the resident's current status and condition, and was not utilized as the basis of the resident's service plan in the following areas:* Bathing and level of assistance needed;* Pain and how pain was expressed, including non-pharmacological interventions;* Skin issues, type, treatment and wound care location;* Transportation assistance;* Complex medication regimen;* Falls; and* Outside service providers, including hospice. The need to ensure evaluations were updated, included relevant data related to the resident's current needs and condition with sufficient information to be used to update the service plan was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

Plan of Correction:

1. Resident evaluation with customary routines and preferences completed for Resident #1 on 10/16/2023.2. At move in, evaluation will be completed to include but not limited to, areas noted in statement of deficiencies. Quarterly evaluation checklist will be completed with each service plan update to ensure all ancillary evaluations are completed at the time of review. Evaluations reviewed and completed for all resident's admitted in the last 30 days.3. Review will occur daily at clinical meeting and as part of the quarterly care planning process.4. Health and Wellness Director and Executive Director, or designee.1. Resident 9's evaluation was reviewed and updated on 2/23/24 to be consistent with her current needs including: addressing her bathing assistance, detailing her pain and how she expresses pain and non-pharmacological interventions specific to the resident, description of her skin deficits including treatment needs, her transportation needs, her complex medication regimen, her fall history and interventions, and her outside service providers. Additionally, resident evaluations will be reviewed for current needs and preferences and completed by 3/17/24.2. Evaluations will be reviewed at each service plan meeting and updated with the service plan. The service plan will be reviewed to verify that the plan is consistent with the current level of resident need and aligns with resident's current preferences. Evaluations will also be brought to care conferences to be reviewed by the care planning team and attached to the signed service plan.3. Evaluations will be updated with each service plan at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition.4. Executive Director, Health and Wellness Director and/or Designee.

Citation #8: C0260 - Service Plan: General

Visit History:

1 Visit: 10/19/2023 | Not Corrected

2 Visit: 2/1/2024 | Not Corrected

3 Visit: 5/29/2024 | Not Corrected

4 Visit: 3/12/2025 | Corrected: 6/28/2024

Inspection Findings:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, and provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, for 3 of 6 sampled residents (#s 2, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 6 was admitted in 06/2023 with diagnoses including sleep apnea, mild neurocognitive disorder, and depression.The resident's 07/15/23 service plan and Temporary Service Plans (TSPs) were reviewed. Resident 6 and staff were interviewed. The following areas were either not reflective on the resident's service plan or lacked clear direction to staff: * The use of a CPAP (continuous positive airway pressure) machine; * How environmental factors impact the resident's behavior; * Behavior interventions relating to the timeliness of medications; and * Where the resident preferred to eat his/her meals.The need to ensure service plans provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.
2. Resident 5 was admitted to the facility in 01/2021 with diagnoses including hypertension. The resident's 08/01/23 service plan and Temporary Service Plans (TSPs) were reviewed and were not reflective of the resident's current needs and lacked clear instruction to the staff in the following areas:* ADL assistance provided by hospice providers;* Assistive mobility devices, use of manual wheelchair;* Treatments, oxygen use; and* Toileting, use of urinal.The need to ensure service plans were reflective of resident needs and included clear instructions to the staff was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 04/2023 with diagnoses including chronic kidney failure stage 4 (severe), Type 2 diabetes mellitus with diabetic chronic kidney disease and major depressive disorder. Observations were made of the resident's care on 10/17/23. Interviews with facility staff and the resident were conducted. The current service plan dated 10/03/23 was reviewed. Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:* Presence of depression and history of treatment; and* Instructions for signs and symptoms of infection to report when providing care to the suprapubic insertion site.The resident's current service plan, dated 10/03/23, was filed in their medical record, which was locked in the medication room and was not readily available to staff. The need to ensure the service plan reflected residents' current needs, provided clear instructions to staff regarding delivery of services, and was readily available to staff was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings. No further information was provided.

2. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition. Resident 8's service plan dated 01/18/24 was reviewed. Observations and interviews with the resident and staff were conducted during the survey. The service plan was not reflective and did not provide clear caregiving instruction in the following areas: * Nutrition: Weight loss and interventions;* Dressing and grooming: One-versus-two person dressing assistance, oral care, no longer could stand to be weighed, and no longer wore compression socks;* Bathing: Shower assistance vs. bed bath from hospice providers;* Bathroom: one-versus two-person assistance for brief changes and frequency of staff checks per shift;* One-versus two-person transfer assistance;* Skin care: interventions and wound care; and* Hospice comfort care interventions.The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans reflected the resident's needs as identified in the evaluation and provided clear direction to staff, which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, for 2 of 4 sampled residents (#s 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 9 moved into the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease and Type 2 diabetes mellitus. The resident's service plan dated 01/12/24 and Temporary Service Plans (TSPs) were reviewed. Observations and interviews with the resident and staff were conducted during the survey. The following areas were not reflective of the resident's current care needs and/or lacked clear direction to staff: * Bathing: Shower assistance vs. bed bath from hospice providers;* Dressing: No indication of who was to assist the resident and how;* Bathroom tasks: No indication of who was to assist the resident and how;* Reluctance to accept care: "was evaluated for hospice but declined admission"; and* Skin care and who provided the wound care treatments. The need to ensure service plans reflected the resident's current care needs and status, provided clear direction to staff, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's needs and preferences, provided clear direction regarding the delivery of services, and was implemented for 1 of 3 residents (#12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 12 was admitted to the facility in 04/2019 with diagnoses including depression, stroke, and arthritis.The resident's 04/28/24 service plan and temporary service plans dated 04/16/24 to 05/28/24 were reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas:* Nectar-thick liquids;* Meal assistance;* Nutritional supplement;* Bed positioning;* Suicidal ideation;* Hearing aids; and* Heel boots.The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) on 05/29/24. She acknowledged the findings.

Plan of Correction:

1. Care Plan for Resident 6 was updated 11/10/23 to include use of CPAP, behaviors and contribution of enviromental factors, and eating preferences. Care plan for Resident 2 updated 11/3/23 to include presence of depression and history of treament as well as instructions for monitoring and providing care for suprapubic insertion site. Care plan for Resident 5 was updated 10/23/23 to include ADL assistance provided by hospice, current use of manual wheelchair, oxygen use, and toileting needs.2. All care plans will be reviewed by care plan team and resident/family to ensure accuracy and updates will be made as needed. Temporary Service Plans (TSPs) and Outside Provider notes will be reviewed at clinical meeting and written onto care plans as appropriate.3. Daily at clinical meeting and with each care plan update.4. Health and Wellness Director and Executive Director, or designee.1. Resident 9's service plan was updated to reflect resident's needs and provide clear direction to care staff in the following areas: shower assistance, dressing, bathroom tasks, reluctance to accept care, and skin care. Resident 8's service plan was updated on 1/31/24 to reflect her current nutrition needs including staff assistance with feeding, nutritional supplements, and weekly weights. Resident 8's service plan was also updated in the follow areas: dressing and grooming, shower assistance, bathroom assistance, transfer assistance, skin care, and hospice coordination and care. Additionally, service plans will be reviewed by 3/17/24 to confirm they provide clear direction to staff regarding how assistance will be provided and who is responsible to provide it.2. Service plans will be reviewed and updated as required. Heath and Wellness Director will sign off on service plans at review. Additionally, service plans will be reviewed at care conferences with the entire care planning team to verify the services align with resident's personal preferences. Signatures will be obtained from care planning team at that meeting acknowledging service plans are reflective of resident's current needs/preferences.3. Care Plans will be updated at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition.4. Executive Director, Health and Wellness Director and/or Designee. 1. Resident #12 service plan was updated with the information found in the Statement of Deficency as well as reviewed for any further updates as needed. An audit was performed on service plans to identify residents that had recent changes in condition and/or high levels of care. These care plans were reviewed for accuracy in care performed, staff direction, and addition personalized information regarding the resident.2. Service plans will be reviewed and updated as required with input from resident, care planning team, and community staff as needed to ensure that they are reflective of resident's current needs, have clear staff direction for cares, and are personalized to suit resident preference and needs.3. Care Plans will be updated at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition.4. Executive Director, Health and Wellness Director and/or Designee.

Visit History:

1 Visit: 10/19/2023 | Not Corrected

2 Visit: 2/1/2024 | Corrected: 12/18/2023

Inspection Findings:

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 medication and treatment refusals. Findings include, but are not limited to: Resident 4 was admitted to the facility in 06/2023 with diagnoses including cervicalgia (neck pain), constipation, and heart failure.The resident's MARs, dated 09/01/23 through 10/16/23, were reviewed and revealed facility staff documented Resident 4 refused the following orders:* Acetaminophen (for pain) on three occasions;* Metamucil (for constipation) on 15 occasions; and * Daily weights on six occasions. On 10/18/23, Staff 2 (Health and Wellness Director) confirmed there was no documented evidence the practitioner was notified of the multiple medication and treatment refusals. On 10/19/23, the need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC). They acknowledged the findings, and no additional documentation was provided.

Plan of Correction:

1. Resident #4's provider was notified of medication refusals.2. Daily at clinical meeting all medication refusals and notifications will be reviewed for completion. Any missed notifications will be completed at this time. Medication refusals and notifications were reviewed for October 2023 for all residents to ensure physican was notified.3. Daily at clinical meeting.4. Health and Wellness Director and Executive Director, or designee.

Citation #15: C0310 - Systems: Medication Administration

Visit History:

1 Visit: 10/19/2023 | Not Corrected

2 Visit: 2/1/2024 | Not Corrected

3 Visit: 5/29/2024 | Corrected: 4/16/2024

Inspection Findings:

Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 3 of 5 sampled residents (#s 3, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including depression and high blood pressure.Physician's orders, MARs dated 09/01/23 through 10/16/23 and progress notes dated 07/17/23 through 10/14/23 were reviewed. The following inaccuracies were found: a. The parameters for administering lisinopril (for high blood pressure) were to notify the RN if "systolic [blood pressure] is above 160 or less than 90; if diastolic [blood pressure] is above 100 or less than 50; pulse is above 100 or less than 60." There were 31 times from 09/01/23 through 10/16/23 that the blood pressures or pulse rate was outside of the parameters. There was no documented evidence the RN was notified.b. Staff were directed to monitor for "significant side effects" related to an anti-depressant and lists the side effects of dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, and decreased appetite. The RN directed staff on each shift to "Document (+) if present and notify MD; (-) if not present." Staff documented "(+)" on 09/12/23, 10/08/23, and 10/14/23. There was no documented evidence the facility contacted the physician on the three dates.Additionally, staff were documenting "NA", "X", "0", "n", "N", and "y" instead of "(+)" or "(-)" as directed, 58 times between 09/01/23 through 10/16/23.d. Staff were directed to monitor the resident for depression on each shift, they were directed to "Document number of times behavior occurs", and "if present attempt non-pharmacological interventions: A - calm approach, B - therapeutic communication, C - decrease stimulation, D - see behavior note." Lastly, staff were to document "E-effective, I-ineffective". There were 42 instances between 09/01/23 and 10/16/23 when staff entered information that was not accurate based on the MAR instruction. The need to ensure residents' MARs were accurate was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.
3. Resident 5 was admitted to the facility 01/2021 with diagnoses including Type 2 diabetes and heart disease.The resident's MAR, dated 09/01/23 through 10/16/23, and physician's orders were reviewed. The following inaccuracies were identified:* Resident 5's physician order for hyoscyamine (for secretions) 0.125 mg tablet directed staff to give every four hours;* Resident 5's MARs for hyoscyamine 0.125 mg tablet directed staff to give one tablet every four hours PRN;* Resident 5's physician order for haloperidol lactate (for agitation) 2 mg directed staff to give every six hours PRN; and* Resident 5's MARs did not reflect the order for haloperidol lactate 2 mg PRN.In an interview with Staff 2 (Health and Wellness Director) on 10/18/23, she acknowledged the order for haloperidol lactate was discontinued by the physician and the MARs were not updated. The need to ensure the MARs were accurate was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including constipation.The resident's 09/01/23 through 10/16/23 MARs and physician's orders were reviewed. The following PRN bowel medications lacked resident specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order: * Fleet enema;* Milk of magnesia; and * MiraLax powder. During an interview on 10/18/23, Staff 9 (MT/Caregiver) confirmed the electronic MAR system did not have parameters on which medication should be administered and in what order listed for staff.The need to ensure resident's MAR was accurate and included resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC). They acknowledged the findings.
3. Resident 10 was admitted in 10/2023 with diagnoses which included hypertension and diabetes.Residents 10's MARs and physician orders were reviewed from 01/01/24 through 01/29/24 and the following was noted:* The physician discontinued an order for Benadryl 25mg one tablet every six hours as needed for rash on 11/21/23. However, the discontinued medication was still listed on the current MAR; and * Resident 10's MAR instructed staff to administer Milk of Magnesia 30 ml as needed for bowel care "if Miralax is ineffective". However, neither the MAR nor record had an order for Miralax. In an interview on 01/31/24 at 3:15 pm, Staff 1 (ED) reviewed the resident's MAR and acknowledged it was inaccurate. She stated the MAR would be updated to reflect current, accurate orders. On 02/01/24 at 2:40 pm, the need to ensure MARs were accurate was discussed with Staff 1 (ED) and Staff 6 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 3 of 3 sampled residents (#s 8, 9, and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition.a. Resident 8's MARs and physician orders were reviewed from 01/01/24 through 01/31/24 and found to be lacking resident-specific parameters and instructions for the following medications:* The MAR included multiple PRN pain medications that lacked clear parameters related to what sequence they should be administered and the MAR did not contain resident specific instructions for staff describing how the resident expressed pain.* The MAR included multiple PRN psychotropic medications for anxiety, agitation, and delirium. The MAR did not contain resident specific instructions for staff describing how the resident expressed anxiety, agitation, and delirium. b. From 01/01/24 through 01/30/24 MT's initialed that they administered a nutritional supplement three times per day. However, interviews with Staff 9 (MT) and Staff 13 (MT) revealed staff had not consistently administered the supplement and the MAR was inaccurate.On 02/01/24, the need for an accurate MAR including resident-specific parameters and clear instruction for unlicensed staff was discussed with Staff 1 (ED) and Staff 6 (RCC). They acknowledged the findings.

2. Resident 9 moved into the facility in 03/2017 with diagnoses including Type 2 diabetes mellitus.The resident's MAR, dated 12/18/23 through 01/29/24, and physician's orders were reviewed. a. The MAR documented the following inaccuracies related to the residents diabetic management:* CBG checks four times per day lacked medication specific instructions for when to notify the provider;* On 12/21/23 CBG value was marked out of parameter however, the CBG value wasn't recorded; and* On 12/30/23 and 12/31/23 sliding scale insulin lispro (for diabetes) was given without documenting the number of units administered. b. The MAR lacked the following related to PRN psychotropic medications:An order for lorazepam every two hours, PRN for anxiety/agitation lacked clear medication instructions that directed unlicensed staff what anxiety/agitation looked like for the resident and when to notify the prescriber or nurse. c. Parameters and clear instructions for the following PRN pain medications:* Apply warm compress every 6 hours, PRN;* Tylenol every 4 hours, PRN;* Hydrocodone every 8 hours, PRN;* Instructions for how long to wait before administering hydrocodone after morphine was already administered; and* Monitor pain every two hours for three days. If asleep do not wake, mark as 02 code (defined on the MAR as med refused) if the resident was asleep. The need to ensure the MARs were accurate was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

Plan of Correction:

1. Training provided to all Med Techs in regards to Resident #6 hold parameters and notifications to the RN. RN clarified parameters for bowel care meds for Resident #3. Resident #5's MAR updated to reflect current physician orders.2. Daily at clinical meeting, MAR documentation as well as new physican orders will be reviewed to ensure MAR accuracy. During quarterly service planning, medication lists will be reviewed for medication parameters and then sent to physician for review. When resident's receives new or updated medication orders they will be monitored for potential adverse side effects and any ongoing interventions related to medications will be added to the care plan. 3. Daily at clinical meeting.4. Health and Wellness Director and Executive Director or designee 1. Re-education was completed with Medication Technicians on 2/8/24 regarding administration of items on the electronic Medication Administration Record. Re-education for Medication Technicians has been scheduled for 3/6/24 on medication administration process and parameters. Resident #8's MAR was updated to reflect instruction for staff regarding the specific instructions describing how to identify pain, anxiety, agitation, and delirium as well instructions on which of resident's pain medications to administer first. Re-education provided on 2/8/24 regarding administration of resident 8's nutritional shake. Re-Education provided has been scheduled for Medication Technicians regarding sliding scale insulin and accurate recording of administered doses. Resident 9's MAR was updated to reflect instructions for unlicensed staff regarding resident's pain medications and how to identify anxiety/agitation. Resident #9's CBGs has been discontinued, so no further intervention needed. Resident 10 had new signed orders on 1/31/24 and MAR was updated to reflecty these orders. 2. At the clinical meeting, select Medication Administration Records and new physican orders will be reviewed to confirm their accuracy. Medication orders with hold parameters will be periodically reviewed. The vitals log for residents with monitored vitals will be sent to their health care provider as needed. Resident orders and medication records will be reviewed by 3/17/24 to verify parameters are present and that notifications are being made to appropriate health care providers. 3. Daily at clinical meeting and additionally as needed.4. Health and Wellness Director and Executive Director or designee.

Citation #16: C0330 - Systems: Psychotropic Medication

Visit History:

1 Visit: 10/19/2023 | Not Corrected

2 Visit: 2/1/2024 | Corrected: 12/18/2023

Inspection Findings:

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#5) who was prescribed psychotropic medications. Findings include, but are not limited to:Resident 5 was admitted to the facility in 01/2021 with diagnoses including depression and anxiety.Review of Resident 5's MAR, dated 09/01/23 through 10/16/23, and physician orders revealed the following:* Clonazepam 0.5 mg (anti-anxiety medication), one tablet every six hours, PRN for anxiety; and* Lorazepam 0.5 mg (anti-anxiety medication), one tablet every six hours PRN for severe agitation. The above PRN psychotropic medications were administered to the resident five times from 10/01/23 through 10/16/23. There was no documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications. In an interview on 10/19/23, Staff 12 (MT) confirmed she was unaware of the non-pharmacological interventions to attempt for Resident 5. On 10/19/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

Plan of Correction:

1. Non-pharmacological interventions were developed and communicated to the staff related to Resident #5's as needed psychotropic. 2. Non-pharmacological interventions for new psychotropic medications will be developed when new orders are received. Exisiting interventions will be assessed for ongoing effectiveness during service planning. All residents with antipsychotic and benzodiazipine medications were reviewed and non-pharmacological interventions were put in place.3. Will be evaluated daily during clinical meeting as needed with new psychotropic medication orders received. Interventions to be reviewed quarterly during service planning.4. Health and Wellness Director and ED

Citation #17: C0361 - Acuity-Based Staffing Tool

Visit History:

1 Visit: 10/19/2023 | Not Corrected

2 Visit: 2/1/2024 | Not Corrected

3 Visit: 5/29/2024 | Not Corrected

4 Visit: 3/12/2025 | Corrected: 1/31/2025

Inspection Findings:

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:The facility's ABST was reviewed and discussed with Staff 1 (ED) on 10/18/23 at 11:30 am. Staff 1 reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident. Three of six sampled resident service plans were not reflective of the resident status which would impact the ABST.There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. Additionally, the staffing hours recommended by the current tool were reviewed and failed to correspond with the number of staff listed on the staffing plan.The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 1 on 10/19/23. She acknowledged the findings. No further information was provided.

Based on interview and record review it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to:The facility previously had a condition placed on the facility's license because the ABST the facility was using didn't meet regulation. During an interview on 01/30/24, Staff 1 (ED) stated the facility was using the "Brookdale ABST".A review of the facility's Acuity Based Staffing Tool (ABST) identified the following:1. 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. The ABST had multiple ADLs grouped together in subcategories. For example, dressing was grouped together with grooming. 3. The tool failed to address the following ADL's, individually:* 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 1 on 01/30/24. She acknowledged the findings.

Based on interview and record review it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to:The facility previously had a condition placed on the facility's license because the ABST the facility was using didn't meet regulation. During an interview on 05/29/24, Staff 1 (ED) stated the facility was using the "Brookdale ABST".A review of the facility's Acuity Based Staffing Tool (ABST) identified the following:1. 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. The ABST had multiple ADLs grouped together in subcategories. For example, dressing was grouped together with grooming. 3. The tool failed to address the following ADL's, individually:* 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 1 on 05/29/24. She acknowledged the findings.

Plan of Correction:

1. Community is in process of working with Corrective Action 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.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.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

2 Deficiencies

Date: 7/28/2023

Type: Complaint Investig., Licensure Complaint

Citations: 3

Survey SZVH

1 Deficiencies

Date: 4/4/2023

Type: State Licensure, Other

Citations: 2

Citation #1: C0000 - Comment

Visit History:

1 Visit: 4/4/2023 | Not Corrected

2 Visit: 7/6/2023 | Not Corrected

Inspection Findings:

The findings of the kitchen inspection, conducted 04/04/23, 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 Sanitation Rules OARS 333-150-0000.

The findings of the first revisit to the kitchen inspection of 04/04/23, conducted 07/06/23, 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.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:

1 Visit: 4/4/2023 | Not Corrected

2 Visit: 7/6/2023 | Corrected: 6/3/2023

Inspection Findings:

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 04/04/23 at 10:50 am, the facility was observed to need cleaning in the following areas: Food spills, splatters, debris, grease, dust/dirt and/or black matter was observed on or beneath the following: * Lower shelves throughout the entire kitchen (beneath steam table, juice and coffee station, food prep counters);* Hood vents above the stove; * Wire shelves on wall near the steam table/refrigerator (above recycling container); * Tub on bottom shelf under toaster containing soup bowls;* Oven doors and handles;* Top and doors of convection oven:* Wall behind convection oven and above shelf of stove;* Wall behind steamer;* Walk in refrigerator walls and ceiling; and* Floor beneath counters/sinks/prep areas/racks throughout the kitchen. Garbage can near ice machine was uncovered when not in use. The areas above were discussed with Staff 1 (Dietary Services Manager), Staff 2 (Executive Director) and Staff 3 (Business Office Staff) on 04/04/23. The findings were acknowledged.

Plan of Correction:

1. Entire kitchen will be deep cleaned on 5/3/2023 including: removing food spills/splatters, debris, grease, dust/dirt and/or black matter from lower shelves throughout the entire kitchen (beneath steam table, juice and coffee station, food prep counters); hood vents above the stove were cleaned; wire shelves on wall near the steam table/refrigerator (above recycling container); tub on bottom shelf under toaster containing soup bowls; oven doors and handles; top and doors of convection oven: wall behind convection oven and above shelf of stove; wall behind steamer; walk-in refrigerator walls and ceiling; and the floor beneath counters/sinks/prep areas/racks throughout the kitchen. Garbage can near the ice machine cover on 4/4/2023. On 4/18/2023 the Dining Services Coordinator received additional training on the cleaning requirements and cleaning schedule per the Dining Services manual and the responsibility of holding staff accountable to the schedule.2. By 4/30/2023 all kitchen associates will undergo inservice on kitchen cleaning procedures. Dining Services Coordinator will routinely review daily, weekly, and monthly cleaning checklists. Executive Director will completely weekly audit of cleaning checklists and visual inspection to ensure compliance of a clean and sanitary kitchen.3. Daily inspections Monday-Friday by Dining Service Coordinator or designee. Weekly review and visual inspection by Executive Director.4. Daily inspections Monday-Friday by Dining Service Coordinator or designee. Weekly review and visual inspection by Executive Director.

Survey J1N3

10 Deficiencies

Date: 12/13/2021

Type: Validation, Re-Licensure

Citations: 11

Citation #1: C0000 - Comment

Visit History:

2 Visit: 2/28/2022 | Not Corrected

3 Visit: 4/19/2022 | Corrected: 4/15/2022

Inspection Findings:

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:Observations of the facility on 12/14 - 12/15/21 revealed the following areas were in need of cleaning and/or repair:* Multiple resident apartment doors throughout the facility had black scuff marks, missing paint and/or gouges; * The elevator entrance by apartment 104 had a gouge in the wall exposing the sheetrock below;* The elevator by apartment 340 had black scuff marks and a panel that was broken at the bottom exposing the wood underneath; and* The carpet in the hallway outside apartment 340 had several stains.The environment was toured and the need to maintain interior surfaces clean and in good repair was discussed with Staff 1 (ED) on 12/15/21. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. This is a repeat citation. Findings include, but are not limited to:During an environmental tour of the facility revealed the interior of the elevator, by Resident Apartment 140, had black scuff marks on the walls, and a panel was broken at the bottom exposing the wood underneath.On 3/01/22, Staff 1 (ED) and the Surveyor toured the environment and discussed the need to ensure interior surfaces were clean and in good repair. He acknowledged the findings.

Plan of Correction:

1) All apartment doors have been inspected, cleaned and painted/repaired as needed. All other areas noted in the statement of deficiencies have been corrected.2) Common area carpets have been placed on a cleaning schedule and will be cleaned monthly, spot cleaning will be completed as needed. Apartment doors are on a monthly cleaning/painting schedule. Immediate repairs will be completed as needed. Maintenance and Executive Director will conduct a weekly walkthrough of all community common areas to note any areas in need of cleaning/repair.3) Scheduled cleaning/painting will occur monthly. Weekly walkthrough will note areas of immediate need.4) Maintenance and Executive Director, or designee.1) Elevator cab has been inspected, cleaned and sanded to ensure no safety risks exist.2) Elevator cab is scheduled to be refurbished. Currently waiting on TK Elevator to receive necessary parts to start work.3) Elevator cab will be inspected weekly to ensure continued safety until work to refurbish cab is completed.4) Executive Director, or designee, will be responsible for continued monitoring.

Facility Information

Violations

Notices

Survey History

Survey KIT004911

Citations: 3

Citation #1: C0240 - Resident Services Meals, Food Sanitation Rule

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Citation #2: C0370 - Staffing Requirements and Training – Pre-service

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Citation #3: C0455 - Inspections and Investigation: Insp Interval

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Survey 6D5Q

Citations: 2

Citation #1: C0000 - Comment

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Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

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Survey 3XKJ

Citations: 22

Citation #1: C0000 - Comment

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Citation #2: C0150 - Facility Administration: Operation

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Citation #3: C0152 - Facility Administration: Required Postings

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Citation #4: C0160 - Reasonable Precautions

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Citation #5: C0200 - Resident Rights and Protection - General

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Citation #6: C0231 - Reporting & Investigating Abuse-Other Action

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Citation #7: C0252 - Resident Move-In and Eval: Res Evaluation

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Citation #8: C0260 - Service Plan: General

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Citation #9: C0262 - Service Plan: Service Planning Team

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Citation #10: C0270 - Change of Condition and Monitoring

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Citation #11: C0280 - Resident Health Services

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Citation #12: C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc

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