Brookdale Wilsonville

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

Based on observation, interview, and record review it was determined the facility failed to have a device to ensure resident safety during an emergency evacuation for 6 of 29 residents ( #s 1, 2, 3, 4, 5, and 6). Findings include, but are not limited to: A review of the 05/31/26 Resident Evacuation Ability Form on 06/22/26 determined six residents (#s 1, 2, 3, 4, 5, and 6) who resided on the third floor of the facility required the use of a slide blanket to assist them down the stairs in the case of an emergency. On 06/22/26 at 11:30 AM, a review of the facility’s emergency evacuation process was performed and no evacuation device to assist residents downstairs was observed in the facility. On 06/22/26 from 12:47 PM through 2:48 PM, Staff 9 (Housekeeper), Staff 6 (Care Partner), Staff 5 (Resident Care Coordinator), and Staff 3 (Maintenance Technician) stated the facility did not have an evacuation device to be used in the case of an emergency for residents who were unable to ambulate down the facility stairs. On 06/22/26 at 2:54 PM, Staff 1 (Executive Director), Staff 2 (RN), Staff 4 (Health and Wellness Director/LPN), and Staff 13 (District Director of Operations) stated a slide blanket to be used for emergency evacuations to assist residents down the stairs was just acquired and they planned to train staff on the use of the device during the time of the survey. The need to have the necessary evacuation assistance device available to assist residents in the case of an emergency was reviewed with Staff 1, Staff 2, Staff 4, and Staff 13 on 06/23/26 at 12:52 PM. They acknowledged the findings.

1. Evacuation Blanket was brought to the community the same day-6/22/26 2. Current staff completed training on the use of the evacuation blanket by 6/23/26. Training on the use of the evacuation blanket will be conducted with new hires as part of the community's overall evacuation training. Ongoing evacuation training for staff will be conducted annually and included in evacuation drills. Signage for location of evacuation blanket will be posted conspicuously. Printed instructions on use will be posted next to evacuation blanket for reference. 3. Executive Director will conduct random audits of Evacuatione Blanket trainings for 30 days and monthly for 60 days. 4. Executive Director, Maintenance Supervisor and designee are responsible for this plan of correction.

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

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 8, and 11) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to: Training records were reviewed on 06/23/26 with Staff 10 (Business Office Manager) and the following was identified: There was no documented evidence Staff 7 (Care Partner) hired 04/02/26, Staff 11 (Care Partner) hired 04/22/26, or Staff 8 (Medication Technician) hired 05/26/26 had completed the following required preservice orientation topics prior to beginning their job responsibilities: * Resident Rights and Values of CBC Care; and * Fire Safety and Emergency Procedures. The need for staff to complete all required pre-services orientation was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 4 (Health and Wellness Director/LPN) and Staff 13 (District Director of Operations) on 06/23/26 at 1:20 pm. They acknowledged the findings. ?

1. Staff # 9,10,11 and 16 have completed fire safety training 2. Remaining staff files will be reviewed to validate completion of Pre-Service orientation topics as described by the rule. Business Office Manager was re-educated on Pre-Service training requirements per rule and associated community orientation training documents. Newly hired staff training compliance will be discussed in manager meeting weekly in order to verify pre-service requirements are met before job specific training begins. 3.Executive Director or designee will conduct random audits of pre-service training documentation weekly for 30-days and monthly for 60-days 4.Executive Director, Business Office Manager and designee are responsible for this plan of correction

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review it was determined the facility failed to perform life safety training on alternating months upon review of a six-month period. Findings include, but are not limited to: Review of fire and life safety records from 01/2026 through 06/2026 revealed life safety training had not occurred on alternating months. The need to ensure life safety training was provided to staff on alternating months from fire drills was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 4 (Health and Wellness Director/LPN), Staff 7 (District RN), and Staff 13 (District Director of Operations) on 06/10/26 at 1:20 pm. They acknowledged the findings. Based on interview and record review it was determined the facility failed to perform life safety training on alternating months upon review of a six-month period. Findings include, but are not limited to: Review of fire and life safety records from 01/2026 through 06/2026 revealed life safety training had not occurred on alternating months. The need to ensure life safety training was provided to staff on alternating months from fire drills was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 4 (Health and Wellness Director/LPN), Staff 7 (District RN), and Staff 13 (District Director of Operations) on 06/10/26 at 1:20 pm. They acknowledged the findings.

1. On June 29, 2026, the Maintenance Supervisor was re-educated on the requirement to provide training on a fire and life safety topic on the alternating months from fire drills. 2. By July 7, 2026, a list will be created with the fire and life safety topics to be covered in the remaining alternate months for 2026. 3. Executive Director or designee will audit the fire and life safety inservice education documentation monthly for 3 months to confirm that a fire and life safety topic was covered on the alternate months from fire drills. After three months, the Executive Director will audit the records quartely thereafter. 4. Executive Director, Maintenance Supervisior and designee are responsible for this plan of correction.

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).

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 05/01/25 at 11:00 am, the facility kitchen was observed to need cleaning and repair in the following areas: * Top of dishwashing machine – significant build of debris (food/chemicals) ; * Dishwashing room caulking on wall of dirty side – significant build up of black matter; * Commercial stand mixer food guard – food splatters; * Ice maker vent – build up of dust; * Top of steamer – dusty; * Wall behind steamer – grease drips/spills; * Sides of deep fat fryer – grease drips/spills; * Ceiling vent above two door refrigerator – significant build up of dust; and * Shelf containing spices above microwave – dusty/debris. Other concern: * Staff with facial hair not using beard restraints. The areas of concern were observed and discussed with Staff 1 (Dining Service Manager) and discussed with Staff 2 (Executive Director) on 05/01/25. The findings were acknowledged.

1. All areas identified during survey in needing cleaning or repair were corrected on 5/7/25 2. All areas identified in needing of cleaning were added to the daily/weekly/monthly cleaning checklists and all associates will be educated on their use on 5/23/25 3. The Dining Services Manager or designee will review cleaning completion 3 times weekly for the next 30 days, and weekly thereafter as part of standard operations. 4. The Executive Director or designee is responsible for this Plan of Correction

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).

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

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

Observations of the kitchen on 01/25/24 identified the following: In all cases for the following items and for cleaning in general we have instituted cleaning log sign off lists for daily, weekly, and monthly cleaning.  The items on the list include items from the original survey, the re-survey, plus other items necessary for proper kitchen sanitation.  I have trained the supervisors on following up with these lists in a timely manner and assigning staff on a regular basis. 1. The interior/exterior of ovens had a build-up of grease and burnt food debris; We have ordered oven cleaner and the sds for the chemical and have put oven cleaning on the monthly cleaning list.  The chemical should arrive on Monday 2/12/24 and the oven will be cleaned that day. 2. The lower shelf of the mixer table was covered with a grayish-white substance; It would appear the the shelf in question has been oxidized by the grill cleaning chemical that is stored there.  That is the white substance seen on the table. We have scrubbed the table smooth and it is clean, it still looks like galvanized steel instead of stainless steel.  I can cover it with contact paper but I feel the metal surface is now in acceptable condition as is and the contact paper would be unnecessarily delicate for the application.  This particular shelf has been placed on the cleaning schedule. 3.  Black residue was on and around the ceiling vent above the dishwashing area; The vent has been cleaned and has been placed on the monthly cleaning schedule. 4.  Numerous saute pans and muffin tins were scorched, tarnished, and heavily scratched; All coated, (non-stick) pans have been discarded and we will utilize the 2 stainless steel skillets we have which are in good condition.  In addition, I have ordered 10" carbon steel skillets to replace the pans I threw out. Carbon steel is superior to non-stick coated pans due to the fact that they will not wear out their coating through scrubbing and over-heating.  These new pans should arrive by 2/14/2024 as are the new muffin tins. 5.  The base of the food processor was broken. A new food processor has been ordered to replace the current food processor with the broken face plate.  It should arrive by 2/14/2024 The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 2 (Dining Services Director) on 01/25/24. They acknowledged the findings.

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

Please see above

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

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

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

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

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

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

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

The findings of the on-site investigation, conducted 09/13/23 through 09/15/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was treated with dignity and respect. Findings include, but are not limited to: Resident 1 returned to the facility after rehabilitation on 04/03/23 with diagnoses including non-displaced fracture of the surgical neck of the right arm. Observations of the resident and interview with staff during the survey showed the resident used a wheelchair for mobility and required staff assistance with bowel and bladder management. The service plan, dated 04/05/23, and a TSP (temporary service plan) dated 04/05/23, indicated the following: * Staff to assist the resident with toileting and showers; and * One person standby assist with transfers and dressing. During an interview on 04/11/23, Resident 1 stated s/he activated the call light for bladder management on 04/08/23, but s/he did not get staff assistance. The resident further stated s/he had to urinate while s/he was on the wheelchair in the room. The failure to provide required care and service as outlined on the service plan in a timely manner resulted in the resident being treated with a lack of dignity and respect. On 4/13/20 at 1:30 pm, the failure to provide care and service with dignity and respect was discussed with Staff 1 (ED) and Staff 2 (District Director clinical RN). They acknowledged the findings. Refer to C 243.

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was treated with dignity and respect. This incident was investiagted; both staff who were scheduled on the evening of this incident had one on one training reviewing each resident's right to dignity and respect. A training for all care staff is scheduled for May 11th, 2023 reviewing resident rights and dignity and respect. In addition to this, an immediate training was conducted with all care staff on the importance of call light responsivness and service plan compliance. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation of an event to rule-out abuse or suspected abuse or to report to the local SPD office for 1 of 1 sampled resident (#1) who was documented to have had a fall with a significant injury. Findings include, but are not limited to: Resident 1 was admitted to the facility in 12/2019 with diagnoses including history of falling. Review of Resident 1's progress notes from 01/17/23 to 04/07/23 during the survey showed the following: * 01/08/23 staff documented the resident had a fall, was sent to the hospital and was transferred to a rehabilitation unit; * 04/02/23 the resident had returned to the community; and * 04/05/23 the resident sustained a nondisplaced fracture of Humerus (the bone of the upper arm) after the fall. An investigation of the fall on 01/08/23 was requested.  On 4/12/23, Staff 1 (ED) stated there was no incident report for the fall with injury and confirmed the incident was not reported to the local SPD office. There was no documented evidence the facility conducted an immediate investigation to reasonably conclude the fall was not the result of abuse and it was not reported to the local SPD office. The surveyor requested Staff 1 to report the incident to local SPD office on 04/12/23. Confirmation the report had been sent to local APD office was provided.

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation of an event to rule-out abuse or suspected abuse or to report to the local SPD office for 1 of 1 sampled resident (#1) who was documented to have had a fall with a significant injury. Investigation of incident was completed and abuse was ruled out, APS was notified of incident. All events will have an investigation completed and documented; any events in which abuse could be suspected will be immediately reported to local SPD office. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide assistance with activities of daily living for 1 of 2 sampled residents (#1) who required assistance with bowel and bladder management. Findings include, but are not limited to: Resident 1 returned to the facility after rehabilitation on 04/03/23 with diagnoses including nondisplaced right arm fracture. Observations of the resident and interview with staff during the survey showed the resident used a wheelchair for mobility and required staff assistance with bowel and bladder management. The service plan, dated 04/05/23, and a TSP (temporary service plan) dated 04/05/23, indicated the following: * The resident "knows to call" for staff help with transfer; * Staff to assist the resident with toileting and showers; and * One person standby assist with transfers and dressing. During the interview on 04/11/23, Resident 1 stated s/he activated his/her call light for bladder management on 04/08/23 in the evening. However, the resident stated s/he did not get staff assistance. The resident further stated s/he had to urinate while s/he was on the wheelchair in the room. During the survey, the call light log from 04/08/23 was reviewed and revealed the following: * The resident's call light was activated at 7:44 pm; and * The call light was not answered until 10:31 pm, 167 minutes after the call light was activated. On 4/13/23 at 1:30 pm, failure to provide assistance with bladder management as outlined on the service plan was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide assistance with activities of daily living for 1 of 2 sampled residents (#1) who required assistance with bowel and bladder management. A training reviewing the importance of responding timely to call lights and following the service plan for each resident was completed on 4/25/23.  Call light times are reviewed from the day before by HWD and ED and reviewed during the morning stand up meeting with staff. All excessive call light times are reviewed and follow up is conducted with staff assigned to the resident during those shifts. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 2) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 01/2023. The new move-in evaluation failed to address the following elements: * Mental health issues including history of treatment and effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * Pain including non-pharmaceutical interventions; and * Recent losses. The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/13/23. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 2) whose move-in evaluation was reviewed. The move in evaluation process was reviewed with staff who complete the move in evaluations for our community. Training was provided to the Health and Wellness Director who completed the referenced move in evaluation. All move in evaluations moving forward will be completed with all the required elements. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 3's current service plans were reviewed during the survey. On 04/13/23 at 10:16 am, Staff 1 (ED) confirmed the facility lacked documented evidence of a Service Planning Team to participate and review the individual service plan. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Both sampled residents have service plan meetings scheduled to include the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident. All residents moving forward will have service plans developed by a service planning team. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were monitored at least weekly until resolved for 1 of 2 sampled residents (# 3) who were reviewed for changes of condition. Findings include, but are not limited to: Resident 3 was admitted to the facility in 02/2021 with diagnoses including hypertension and cerebral infarction. Resident 3's progress notes and facility records dated 01/20/23 through 04/10/23 were reviewed and revealed the following changes of condition: * Falls on: 01/21/23, 01/22/23 and 01/31/23; and * The resident started an antibiotic on 1/25/23. There was no documented evidence the facility monitored the changes of condition at least weekly until resolved. The need to monitor the changes of condition at least weekly until resolved was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were monitored at least weekly until resolved for 1 of 2 sampled residents (# 3) who were reviewed for changes of condition. A Care Staff Meeting was conducted on 3/31/23 to review alert charting and changes of condition with care staff. Charting will be audited by the Health and Wellness Director, ED, or designee weekly to ensure residents are being monitored until resolved. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

2. Resident 5 was admitted to the facility in 06/2023 with diagnoses including anxiety disorder. Progress notes and Temporary Service Plans (TSP) dated 06/26/23 through 07/18/23 indicated the following: * 06/26/23: New environment, move-in. There was no documented evidence the change was monitored through resolution. On 07/20/23, the above finding was reviewed with Staff 7 (ED 2) and Staff 8 (ED 3). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and interventions determined, documented, and monitored until resolution for 2 of 2 sampled residents (#s 4 and 5) ) who experienced changes of condition. This is a repeat citation. Findings include, but not limited to: 1. Resident 4 was admitted to the facility in 06/2023 with diagnoses including type two diabetes and chronic kidney disease. A review of the resident's clinical records, from 06/12/23 through 07/20/23, indicated the resident moved into the facility from independent living following a 51-day stay at an acute rehabilitation center. The following changes of condition had not been reviewed by the facility or monitored to resolution: * There was no evidence the facility had monitored the resident after the initial move-in regarding his/her adjustment to a new living environment; and * On 06/21/23 a HH PT provider collaboration note documented that the resident "expresses signs of depression." During the survey, the resident was observed and interviewed on 07/20/23 at 10:20 am in his/her apartment, sitting in a recliner chair. While talking with the surveyor, the resident expressed a disinterest in participating in physical therapy and leaving his/her apartment. According to a staff interview on 07/20/23 at 11:00 am, Staff 14 (MT) revealed: * Resident 4 stayed in his/her apartment all day and did not attend meals in the dining room; * The resident was not actively participating in PT and was not interested in activities; and * At times required a two-person assist with transfers and repositioning. On 07/20/23 at 11:45 am, Staff 9 (Health Wellness Director, LPN) indicated the resident was more socially withdrawn and had a decreased appetite. The resident continued to display mood disturbances, and there was no documented evidence the facility had evaluated the resident, determined an action or intervention, nor was the resident's status monitored until resolution. The changes of condition were reviewed and discussed with Staff 7 (ED 2) and Staff 8 (ED 3) on 07/20/23. They acknowledged the findings.

1. Resident (s) will be placed on Alert charting for monitoring and outside provider notes will be reviewed for any changes and documented by appropriate staff, followed by the triple check process to ensure proper documentation. 2. All residents on Alert charting will be montiored by HWD, residents on alert will be reviewed to ensure each shift has documemented appropriatly, HWD will ensure all charting is completed and closed after appropriate documetation is completed. 3. HWD will review alert charting daily (5 days a week) for each resident that is on on alert charting or change of condition to ensure that all shifts have completed documention for alert charting and any change of condition until resolved, in the absence of HWD the RCC will ensure that all charting is completed by each shift until resolved. The ED will ensure that this rule is met by reviewing the documentation daily (5 days a week) and reporting to the HWD and RCC for correction.

Based on interview and record review, it was determined the facility failed to implement an acuity based staffing tool (ABST) that met the regulation. Findings include, but are not limited to: 1. During a review of the facility's ABST on 04/11/23 through 04/13/23, it was determined the tool failed to include all of the 22 required ADL components to include: * Personal hygiene; * Transfer in and out of bed or a chair; * Repositioning in bed or chair; * Assisting with leisure activities; * Assisting with communication, assistive devices for hearing, vision, speech; * Responding to call lights; and * Safety checks, fall preventions. 2. Review of Resident 1's records revealed the following: Resident 1 was re-admitted to the facility in 04/2023 with diagnoses including the right arm fracture. Interview with the resident and the call light log reviewed during the survey showed the resident used call light between 5 times and 10 times a day. However, the facility ABST tool failed to address the time spent for the resident's call lights. The ABST tool was reviewed and discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/12/23 and 04/13/23. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity based staffing tool (ABST) that met the regulation. 1. Community is in process of working with Corrective Action on ABST. A call was held with the Department to review where to find 22 elements within Brookdale's Wilsonville 2. As we work through our ABST review with the department, will continue with mandated staffing which mirrors Brookdale's minimum safety guidelines. 3. We will increase our staffing as our Brookdale ABST recommends in the event that it exceeds current mandated staffing by the department. 4.The Executive Director  and/ or designee is responsible for this plan of correction

Based on interview and record review, it was determined the facility failed to implement an acuity based staffing tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to: 1. Review of Resident 4 and Resident 5's ABST records revealed the following: * The ABST tool failed to include all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide each task. 2. During a review of the facility's ABST on 07/19/23 and 07/20/23, it was determined the tool failed to include all of the 22 required ADL components to include: * Personal hygiene; * Transfer in and out of bed or a chair; * Repositioning in bed or chair; * Assisting with leisure activities; * Assisting with communication, assistive devices for hearing, vision, speech; * Responding to call lights; and * Safety checks, fall preventions. The ABST tool was reviewed and discussed with Staff 7 (ED 2) and Staff 8 (ED 3) on 07/20/23. Staff acknowledged the findings.

1. As we continue to partner with DHS on reviewing our ABST tool, we will continue to follow the minimum staffing standard as outlined in our condition. 2. Our home office team will continue to establish proper communication with DHS regarding the ABST tool and the 22 elements that make up the ABST tool, we will continue to staff according to the ABST staffing pattern 3. This will be evaluated by the HWD/RCC to ensure that proper staffing levels are scheduled according to the 22 elements 4.The Executive Director is responsible to ensure that our staffing levels are appropriate as defined by our staffing tool and our mandated staffing pattern.

Based on interview and record review, it was determined the facility failed to fully implement an Acuity-Based Staffing Tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to: During an interview on 10/10/23, Staff 7 (ED 2) stated the facility was using the "Brookdale ABST," and she was aware that the Department had previously placed a condition on the facility's license because the Acuity-Based Staffing Tool the facility was using didn't meet the regulation. A review of the facility's ABST identified the tool failed to include all 22 activities of daily living (ADL's) outlined individually. It had multiple ADLs grouped together. The ABST tool was reviewed and discussed with Staff 7 and Staff 9 (Health Wellness Director, LPN) on 10/10/23. They acknowledged the findings.

Corporate will continue to establish proper communication with DHS regarding the ABST tool and the 22 elements that make up the ABST tool, we will continue to staff according to the ABST staffing pattern This will be evaluated by the HWD/RCC to ensure that proper staffing levels are scheduled according to the 22 elements The ED will oversee that the staffing levels are correct according to the 22 elements.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 4, 5 and 6) completed infectious disease prevention training prior to beginning job duties. Findings include, but are not limited to: Staff training records were reviewed on 04/12/23 and 04/13/23. There was no documented evidence Staff 4 (MT), Staff 5 (Receptionist) and Staff 6 (Server) completed required infectious disease prevention training. The need to ensure newly hired staff completed the required infectious disease prevention training was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 4, 5 and 6) completed infectious disease prevention training prior to beginning job duties. Our training program now ensures that all staff hired moving forward will complete infectious disease prevention prior to beginning their job duties. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and to provide fire and life safety instruction to staff on alternate months, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records dated 08/2022 through 03/2023 were reviewed on 04/12/23 and 04/13/23. The following was identified: a. Fire and life safety training was not provided to staff on alternate months. b. Fire drills were not consistently completed every other month. c. Fire drill documentation did not consistently include one or more of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Number of occupants evacuated. The need to follow all OFC requirements pertaining to staff instruction in fire and life safety and fire drills and documentation was discussed with Staff 1 (ED) and Staff 2 (District Director Clinical RN) on 04/12/23 and 04/13/23. They acknowledged the findings. No additional information was provided.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and to provide fire and life safety instruction to staff on alternate months, as required by the Oregon Fire Code (OFC). Fire and life safety training was provided to staff at the April All Staff Meeting on 4/28/23. A fire drill is scheduled for May 23rd, 2023. A schedule for the remainder of the year for fire drills and fire and life training will be completed and followed to ensure compliance by May 31st, 2023. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures annually. Findings include, but are not limited to: Fire and life safety records were requested and reviewed during the survey. The following deficiencies were identified: * Documentation of annual fire and life safety training provided to residents. The need to ensure residents received fire and life safety training at least annually, was discussed with Staff 1 (Executive Director) and Staff 2 (District Director of Clinical RN) on 04/12/23 and 04/13/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures annually. A schedule has been completed to ensure all residents are instructed on the fire and life safety procedures by May 15th, 2023. Moving forward each resident will have a review of the fire and life safety procedures at their quarterly service plan meetings. The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 270 and C 361.

See previous referral tag

Based on interview and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 361.

See previous referal tag

The findings of the re-licensure survey conducted 04/11/23 through 04/13/23 are documented in this report. The survey was conducted to determine compliance with the OAR 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OAR 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the relicensure survey of 04/13/23, conducted 07/19/23 through 07/20/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the relicensure survey of 04/13/23, conducted 10/10/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 04/13/23, conducted 03/13/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 12/20/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

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

OAR 411-054-0300 (1)(a) POC: 1. By 11/19/2022, Conduct staff meeting and present the Powerpoint provided by Sara O'Dell, "CBC Provider Kitchen Inspection" and "Demonstrating Knowledge in the CBC Kitchen. 2. In staff meeting: review CBC Annual Kitchen Inspection. 3. Review each detailed observed deficiency with staff, visiting each area and demonstrating the correction. 4. Develop a cleaning schedule based on the staffing positions in the dietary department and train each position in their daily, weekly, and monthly responsibilities. 5. Add typical kitchen cleaning to this list as needed. 6. Manager to review and follow up on the new cleaning lists after training is completed. 7. Manager to meet with each staff member weekly until training is verified. 8. ED and DSM to complete CBC Annual Kitchen Inspection quarterly to insure continued compliance.

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

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