The Butte

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

Observations of the facility kitchen, food storage areas, food preparation, and food service were made on 11/04/24.

a. Splatters, spills, drips, and debris noted on:

* Interior of oven;
* Stove hood;
* Walls throughout the kitchen;
* Door to and flooring throughout the walk in refrigerator;
* Interior of the stainless steel residential size refrigerator; \* Dry storage area flooring and food containers;
* Dishes and cookware stored on open shelving;
* Cabinet doors and shelving;
* Stainless steel preparation tables and shelving;
* Carts; and
* Equipment throughout kitchen.

b. The cover to the ice machine was not properly sealed and the machine had a leak causing water to drip onto the floor.

On 11/04/24 at 1:08 pm, the kitchen and the areas in need of cleaning and repair were reviewed with Staff 1 (Operations Support Specialist). He 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 interview and record review, conducted during a site visit on 03/25/24, it was confirmed the facility failed to ensure implementation of resident services for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of the facility's internal investigations, dated 01/13/24, indicated on 01/13/24 Resident 1 became agitated during a facility power outage and a staff member grasped Resident 1's forearms. In a second instance, on 01/13/24, Resident 1 refused to evacuate to the facility's designated safe-area and a staff member held Resident 1 by the arms to take him/her to the designated safe-area. A review of Resident 1's behavior support plan, dated 12/04/23, indicated staff are not to make physical contact with Resident 1 while in a combative-state.In an interview on 03/25/24, Staff 1 (Administrator) stated there were two instances during the facility wide power outage in January where staff made physical contact with Resident 1. In one of those instances Resident 1 was holding the staff member by the collar. Staff 1 indicated s/he has a zero-tolerance policy for staff putting hands on a resident and both staff members were terminated. The facility failed to ensure implementation of resident services. The findings were reviewed with and acknowledged by Staff 1 on 03/25/24.Verbal Plan of Correction: Staff members involved were terminated. All staff have also received in person de-escalation training. on all shifts. An in-service training was conducted for all staff and Resident 1's service plan was reviewed including strategies for getting out of holds without putting hands on residents. At an all-staff another training regarding Resident 1's service plan and ensuring staff know how to get out of holds without putting hands on a resident.

Based on interview and record review, conducted during a site visit on 03/25/24, it was confirmed the facility failed to show in detail with supporting documentation all monies received on behalf of the resident and the disposition of all funds received, and providing a list showing description and price of items purchased along with payment receipts for items for 1 of 1 sampled resident (#2). Findings include, but are not limited to: A review of Resident 2's trust transaction history, dated 06/01/23 - 03/25/24, and supporting documentation indicated there were 6 transactions for a total of $107.42 in 2023 from Resident 2's trust account that did not have either supporting resident signed cash vouchers or receipts for items purchased on behalf of Resident 2. In an interview on 03/25/24, Staff 1 (Administrator) stated the business office manager (BOM) who was in charge of maintaining resident personal incidental fund (PIF) accounts quit after being questioned about transactions on Resident 2's account. The facility completed an audit of Resident 2's account and determined there was missing supporting documentation for funds used on behalf of Resident 2 and the facility has credited Resident 2's account for the sum of those transactions. The facility failed to show in detail with supporting documentation all monies received on behalf of the resident and the disposition of all funds received, and providing a list showing description and price of items purchased along with payment receipts for items. The findings were reviewed with and acknowledged by Staff 1 on 03/25/24.Verbal Plan of Correction: BOM responsible for resident PIF funds no longer works for facility. An audit was conducted of all resident PIF funds to ensure all accounts were rectified and had all necessary supporting documents and any funds that were used without supporting documents were refunded to resident account. Another audit will be conducted next month to ensure any missing funds or unaccounted for funds are refunded to residents.

The findings of the change of ownership survey, conducted 06/27/23 through 06/29/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the re-licensure survey of 06/29/23, conducted 11/06/23 through 11/07/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents relating to unsecured chemicals. Findings include but are not limited to: On 06/27/23 at 10:35 am the facility's interior environment was toured. There was an unlocked janitor closet in the Resident Care Facility, containing cleaning supplies and chemicals. On 06/28/23 at 9:06 am, the same janitors closet was observed unlocked. The area was readily accessible to residents, and posed a safety risk. On 06/29/23 the need to ensure reasonable precautions were exercised was discussed with Staff 1 (Administrator) and Staff 2 (Senior Regional Director of Operations). They acknowledged the findings.

3. Resident 1 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease and was at risk for falls. On 06/28/23 at 10:00 am, the resident confirmed that s/he didn't use the call system as, "the girls check on me during the day."Staff interviews conducted on 06/28/23 confirmed providing safety checks at least once an hour. Resident 1's service plan, dated 06/07/23 lacked clear direction regarding the delivery of services in the following areas: * Ability to self manage a "sponge bath";* Assistance with dressing on shower days; and * Frequency of safety checks. The need to ensure service plans provided clear caregiving direction was discussed with Staff 1 (Administrator), Staff 2 (Senior Regional Director of Operations), Staff 3 (Regional RN Consultant), and Staff 5 (Special Needs Contract RCC) on 06/29/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 10/2021 and was noted to have a history of skin impairment. The resident's 06/13/23 service plan, temporary service plans and outside provider communication forms were reviewed during the survey.The service plan failed to provide clear instruction to staff regarding Resident 2's skin care in the following areas:* Assist with repositioning every hour to prevent skin breakdown;* Apply lotion to skin every morning to prevent dry skin; and* Use of an alternating pressure mattress when in bed. The need to ensure Resident 2's service plan was accurate and provided clear instruction to staff was discussed with Staff 1 (Administrator) and Staff 3 (Regional RN Consultant) on 06/29/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services and were followed by staff for 3 of 4 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 05/2023 with diagnoses including bipolar disorder, major depressive disorder with psychotic features, neurocognitive disorder and a suicide attempt. The resident's record was reviewed, the resident was observed, and staff were interviewed. Resident 3's service plan dated 06/13/23, and behavioral plan dated 05/05/23, lacked clear direction regarding the delivery of services including a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following areas: * Monitoring during meals;* Frequency of safety checks;* Room sweeps for items that can potentially be used for self-harm;* Vision;* Interventions related to depression; and * Fall interventions related to footwear and encouragement to use assistive device while ambulating. The need to ensure service plans provided clear caregiving direction which included a written description of who shall provide services and what, when, how and how often the services shall be provided was discussed with Staff 1 (Administrator), Staff 3 (Regional RN Consultant) and Staff 5 (Special Needs Contract RCC) on 06/29/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease. The resident's progress notes, dated 03/29/23 through 06/27/23 and temporary service plans were reviewed and revealed the following: * 04/03/23 - Scratch on left underarm; * 05/30/23 - Diarrhea; and* 06/22/23 - "Not feeling well."There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated the actions or interventions to staff on each shift and monitored the conditions with progress noted at least weekly through resolution for each of the resident's changes of condition.The need to ensure changes of condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift and conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Senior Regional Director of Operations), Staff 3 (Regional RN Consultant), and Staff 5 (Special Needs Contract RCC) on 06/29/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated to determine what actions or interventions were needed, action or interventions were communicated to staff on each shift and conditions were monitored with progress noted at least weekly for 2 of 4 sampled residents (#s 1 and 3) who experienced changes of condition. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 05/2023 with diagnoses including history of bipolar and skin picking disorders. The resident's progress notes, dated 05/09/23 through 06/27/23 and temporary service plans were reviewed and revealed the following: * 05/12/23 - Resident to resident aggressive behavior;* 05/11/23 - Scratches to bilateral upper extremities; and* 06/18//23 - Dime sized wound to chest.There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated the actions or interventions to staff on each shift and monitored the conditions with progress noted at least weekly through resolution for each of Resident's 3's short-term changes of condition.The need to ensure changes condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift and conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 3 (Regional RN Consultant) on 06/29/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to determine weekly minutes needed for all care needs were accurately documented on the Acuity Based Staffing Tool (ABST) relating to the ABST and the residents' service plans for 2 of 4 sampled residents (#s 1 and 3) whose ABST information was reviewed. Findings include, but are not limited to: 1. Resident 1 and staff were interviewed. The service plan, dated 06/07/23, 06/01/23 through 06/27/23 MAR, and progress notes dated 03/29/23 through 06/27/23 were reviewed. On 06/28/23 at 10:00 am, Resident 1 verified s/he required assistance with bathing, housekeeping and laundry. The resident also confirmed not using the call light but verified that staff checked in with him/her throughout the day.An interview with multiple staff on 06/28/23 verified the resident received assistance with bathing, hourly or more safety checks, and received treatments once a day scheduled and three times a day PRN. Resident 1's service plan provided direction to staff in the following areas: * Non-drug related interventions for behaviors; * Muscle rub (topical cream), repositioning and elevating legs related to pain interventions; * Cueing to change position; * Encourage to drink fluids; * Bathing assistance; * Housekeeping; and * Laundry services. A review of Resident 1's ABST revealed an inaccuracy of minutes assigned in the following areas: * Bathing; * Repositioning in bed or chair; * Supervising, cueing, or supporting while eating; * Providing non-drug interventions for pain management; * Providing treatments; * Providing non-drug interventions for behaviors;* Safety checks, fall prevention; and * Completing resident specific housekeeping or laundry services. The need for the facility to use the ABST to determine the time needed for all care needs was reviewed with Staff 1 (Administrator), Staff 2 (Senior Regional Director of Operations), Staff 3 (Regional RN Consultant), and Staff 5 (Special Needs Contract RCC) on 06/29/23. They acknowledged the findings.
2. Resident 3 was observed and staff were interviewed. The residents service plan and behavior support plan, dated 06/13/23 and 05/05/23 respectively, were reviewed. During observations of Resident 3 on 06/27/23 at 12:15 pm the resident was eating in his/her room at bedside and there was no evidence the resident was being monitored by staff for that meal.An interview with Staff 12 (Special Needs Contract CG) on 06/27/23 at 11:20 am revealed she did not provide nail care other than trimming nails as needed. Documentation showed the resident had behaviors associated with toileting habits which required staff to check his/her nails after toileting and bathing for infection prevention. After the interview, Staff 12 was observed to assess Resident 3's nails and provided supervision to wash his/her hands in the sink. Staff 12 also stated that she provided the resident assistance with dentures. An interview with Staff 14 (CG) on 06/28/23 at 3:20 pm revealed she was not aware of the need to provide nail care for prevention of infection. She also assisted Resident 3 with dentures. Staff 12 and Staff 14 both stated that Resident 3 did not need any help with eating but they made sure there were no sharp utensils being used. The resident's service and/or behavior plan provided direction to staff in the following areas: * Monitor during meals;* Grooming, including nail care; and* Oral hygiene for dentures. A review of Resident 3's ABST revealed an inaccuracy of minutes assigned in the following areas:* Eating; * Grooming; and * Personal hygiene.The need for the facility to use the ABST to determine the time needed for all care needs was reviewed with Staff 1 (Administrator) on 06/29/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and maintained in good repair. Findings include, but are not limited to:On 06/27/23 at 10:35 am, the facility was toured and the following were identified: 1. Exterior: * Lint debris located behind the exterior wall of the laundry room; * Exposed wiring from antenna on the ground; * Approximately a three inch gouge in a pillar at the entrance of the facility;* A metal handrail located outside of the exit door to the left of the laundry room was in disrepair;* A drop-off directly across the exit door to the smoking area measured greater than four inches; * Cement was cracked and falling off the bottom portion of an exit door located in the left back section of the building; * Three resident rooms' window screens were observed to be in disrepair or missing from resident windows; and* Door ramps were not the same width as the door frames which posed a hazard for entering and exiting the building. The interior of the building was observed in disrepair: 2. Interior:* A wooden stool with chipped paint was observed in the shower room;* A dryer located in the main laundry room was missing a handle; * Dead bugs, cobwebs, brown debris and shoes were observed along windowsill in the laundry room;* Vents throughout the facility, including the public use restrooms, were in need of cleaning; * Chipped, dinged, gouged, scratched and scuffed walls, doors and door frames were observed throughout the facility;* There was brown debris observed inside room 6's toilet and the flooring had a dark yellow stain to the left of the restroom's door;* Room 14 was observed to have a unclean toilet; * There were multiple areas where the lights had been replaced in the ceilings that needed painting or hole repair; * A rug located in the secured courtyard outside of the dining room was permanently folded and posed a tripping hazard; and* The right side, public use restroom located in the Residential Care Facility, had a hole located behind the door. * Room 6 had a pervasive urine odor during the time of survey.The environment was toured on 06/29/23 with Staff 1 (Administrator) and Staff 2 (Senior Regional Director of Operations). They acknowledged the above mentioned findings.

Based on interview and observation, the facility failed to ensure residents had a key for the lockable storage space (e.g., drawer, cabinet, or closet) provided for the safekeeping of small valuable items and funds for 3 of 4 sampled residents (#s 1, 3 and 4) reviewed for having a key to their lockable storage space. Findings include, but are not limited to:On 06/28/23 at 10:00 pm, Resident 1's room was observed to have a lockable storage space located in the unit's closet. When asked if the resident had a key to the lockable storage, Resident 1 confirmed s/he did not have a key. Resident 3 and 4's units were also observed and it was confirmed the residents did not have keys to their lockable storage space.The need to ensure all residents were provided keys to their unit's lockable storage space was discussed with Staff 1 (Administrator) on 06/29/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure soiled linens and clothing were stored in closed containers, the arrangement provided a one-way flow of soiled items from the soiled area to the clean area, had a flushing rim clinical sink with a handheld rinsing device, had an operable hand wash sink or lavatory, and provided a covered or enclosed clean linen storage in the laundry room. The findings include, but are not limited to:Observation of the laundry room on 06/27/23 at 1:19 pm revealed the following: * There was no separate area with closed containers which ensured separate storage and handling of soiled items with space and equipment to handle soiled linen and clothing processing needs that was separate from regular linens and clothing.* The arrangement did not provide a one-way flow of soiled linens and clothing from the soiled area to the clean area in order to preclude potential for contamination of clean linens and clothing.* There was no flushing rim clinical sink with a handheld rinsing device or an operable hand wash sink or lavatory.* The clean linen storage was not covered. The need to ensure the laundry room had a separate area with closed containers to allow for the storage and handling of soiled linens and clothing, had a one way flow of soiled linens and clothing, had a flushing rim clinical sink with a handheld rinsing device, had an operable hand wash sink or lavatory, and ensured clean clothes and linens were covered was discussed with Staff 1 (Administrator) and Staff 2 (Senior Regional Director of Operations) on 06/29/23. They acknowledged the findings.

Based on observation and interview, the facility failed to ensure extension cords were not used in the building. Findings include, but are not limited to: On 06/28/23 at 10:00 am, an extension cord was observed in Resident 1's room. The resident utilized an electric recliner. During the interview, Resident 1 stated, "There aren't enough outlets in here."On 06/29/23 at 11:13 am, an extension cord was observed in the kitchen. There was an air conditioning unit facing the dishwashing area, connected to an extension cord in a small puddle of water which was plugged into the wall. The need to ensure there were no extensions cords in the building was discussed with Staff 1 (Administrator) and Staff 2 (Senior Regional Director of Operations) on 06/29/23. They acknowledged the findings and removed the extension cord out of the puddle of water immediately.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units per evaluated need. Findings include, but are not limited to:Review of records for Residents 1, 2 and 4 revealed no documented evidence the residents had been evaluated for the ability to manage keys to their rooms.On 06/28/23 at 10:00 am, Resident 1 stated that although s/he had a key to her unit's door, the key did not work, which was verified by the surveyor. Review of records for Residents 1, 2 and 4 revealed no documented evidence the residents had been evaluated for the ability to manage keys to their rooms.The need to ensure all residents were evaluated for the ability to manage keys to their units and providing keys based on those evaluations was discussed with Staff 1 (Administrator), Staff 2 (Senior Regional Director of Operations), Staff 3 (Regional RN Consultant), and Staff 5 (Special Needs Contract RCC) on 06/29/23. They acknowledged the findings.

The findings of the kitchen inspection, conducted 04/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules 333-150-0000.

The findings of the first re-visit kitchen inspection of 04/27/23, conducted 06/27/23 through 06/29/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.


The findings of the second re-visit kitchen inspection of 04/27/23, conducted 11/06/23 through 11/07/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services-Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure equipment was clean and appropriate food preparation practices were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 04/27/23 at 11:05 am, the facility kitchen was observed to have the following concerns: * The residential type refrigerator did not have a thermometer to monitor the temperature; * The walk in refrigerator had uncovered/undated food items: cake, sausage links, Jello, muffins and box of cranberries; * One garbage can located near the steam table and coffee maker was uncovered when it was not in use; and* The microwave oven interior had food splatter/debris. The concerns were observed and discussed with Staff 1 (Dietary Manager) and Staff 2 (Executive Director) on 04/27/23. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: On 06/27/23 through 06/29/23, the facility kitchen was observed to have the following concerns: * The walk-in refrigerator temperature was observed on 06/27/23 at 49 degrees Fahrenheit at 10:03 am, 48 degrees Fahrenheit at 11:21 am, and 39 degrees Fahrenheit at 2:00 pm; and * Temperatures were taken on three protein-based food items on 06/29/23 at 12:50 pm; - Mayonnaise: 51 degrees Fahrenheit, - Leftover ground meat: 51 degrees Fahrenheit, and - Cream cheese: 54 degrees Fahrenheit. Per Food Sanitation Rules, protein-based foods must be held at a temperature of 41 degrees Fahrenheit or less. The concerns were discussed with Staff 2 (Administrator), Staff 3 (Dietary Director), and Staff 4 (Senior Regional Director of Operations) on 06/29/23. Staff 4 confirmed the above mentioned items were higher than 41 degrees Fahrenheit by obtaining the temperatures herself.

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