Sweetbriar Villa

Based on observations and interviews, it was determined the facility failed to maintain the kitchen in a sanitary manner and serve food at palatable temperatures and appropriate textures in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the kitchen on 06/05/25 at 10:45 am through 1:00pm revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, around or underneath the following:

* Kitchen drains
* Industrial mixer and slicer
* Industrial can opener
* Metal large can rack
* Metal shelf above cooking area
* Interior of stainless-steel drawers
* Juice machine
* Lids of bulk bins
* Popcorn maker
* Stainless-steel shelving

b. The following areas were in need of repair:

* Light switch cover cracked
* Area around floor electrical outlet in Dining room with gap in caulking.

c. Both surface sanitizer buckets were found not a proper concentration (Parts Per Million) for effective sanitizing. Facility’s test strips did not turn any color indicating zero active sanitizing chemical available in the red buckets meant for sanitizing surfaces. Facility made fresh buckets and were found at appropriate PPM for sanitizer concentration.

d. Multiple food items were found not dated when opened.

e. Multiple containers of bulk dry goods had cups or scoops stored in them with the handles or hand contact surfaces touching the food product potentially contaminating the items.

f. The small memory care refrigerator was noted at 48 degrees. The facility was not able to demonstrate an effective process for monitoring the mini fridge temperatures for cold food storage. Multiple resident food items were observed stored in that refrigerator.

g. Some items in reach in freezers were observed not fully covered/protected from potential contamination.

h. Two residents on minced and moist diet textures were served minced meat but with bbq sauce poured on top. For this diet type mixed textures are not permitted and must be thoroughly mixed into the product yielding one texture. The temperature of the BBQ pork was also noted to be at 118 degrees Fahrenheit and was about to be served to the residents at that lower temperature. Surveyor interviewed and instructed that food must be hot held and leave the kitchen at 135 degrees or hotter. Staff 2 (Dining Services Director) acknowledged the food was not hot enough and was going to be served at unpalatable temperatures. Food was reheated to a higher and more palatable temperature before served to residents.

i. Caregiving staff in memory care unit that were assisting residents with their meals did not have aprons/protective barriers on to prevent possible contamination from their clothing during meals.

j. Industrial slicer was observed uncovered and not protected from potential contamination when stored/not in use.

At 12:45 pm, the surveyor reviewed above identified areas with both Staff 1 (Executive Director) and Staff 2 who acknowledged the of areas in need 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).

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen and handle and serve food items in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the kitchen on 06/05/25 at 10:45 am through 1:00pm revealed the following:


a. The following area was in need of repair:
* Floor electrical outlet in the Assisted Living dining room with gap in caulking.


b. The surface sanitizer buckets were found not at a proper concentration (parts per million) for effective sanitizing. The solution tested at 100 parts per million. Staff 2 (Dietary Services Manager) stated that he believed the solution should be 150 ppm and showed documentation of daily sanitizing bucket checks throughout 08/2025 where the solution was noted to be 150 ppm. The facility utilized QT-10 strips for quaternary ammonia which requires the solution to test at 200 parts per million for effective sanitizing. Staff 2 remade the sanitizing solution, which continued to read at 100 ppm. The facility was unable to demonstrate a system for creating a sanitizing solution of an effective concentration for sanitizing.


c. A container of bulk dry goods had a cup stored in it with the hand contact surfaces touching the food product, potentially contaminating the item.

d. A box of hamburger patties in the reach in freezer was observed not fully covered to protect from potential contamination.

e. At 12:16 pm, a hamburger patty was observed being removed from the hot hold area to be served to a resident. The hamburger was tested to be 92 degrees F. Surveyor reviewed that hot food must be 135 degrees F or greater when removed from hot holding temperature control. Staff 2 stated that there was no current system for testing food temperatures when removed from the hot holding area to ensure hot items are at least 135 degrees F.

f. Caregiving staff in MCC unit who were assisting residents with their meals did not have aprons/protective barriers on to prevent possible contamination from their clothing during meals.


The need to ensure the kitchen was maintained and food served in accordance with the Food Sanitation Rules was reviewed with Staff 1 (Executive Director) and Staff 2 on 08/26/25 at 12:50 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

Refer to: C240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:

Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to: C240.

OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to:A review of Resident 1's August 2024 MAR and progress notes, incident report dated 08/14/24, and Interim Service Plan dated 08/15/24 indicated the following:· Novolog 100-U/ML PEN 3ML to be injected 11 units before breakfast and 10 units before lunch and dinner for diabetes.· Tresiba 100-U/ML PEN 3ML to be injected 18 units every day at 8 pm for diabetes.· Resident 2 did not receive his/her Novolog 100-U/ML PEN 3ML on 08/14/25 at 7:30 am and 11:30 am and was administered Tresiba 100-U/ML PEN 3ML in error before breakfast and lunch.In an interview, Staff 2 (Wellness Nurse) stated the incident had occurred.The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 03/25/25.The facility's failure to carry out medication and treatment orders as prescribed was substantiated.Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#2). Findings include, but are not limited to:A review of Resident 2's November 2023 MAR and progress notes, incident report dated 11/09/23, and Interim Service Plan dated 11/10/23 indicated the following:· Tramadol 50mg Tab to be given twice daily at 8 am and 2 pm.· Resident 2 did not receive his/her scheduled doses of Tramadol on 11/09/23 at 8 am and 2 pm.In an interview, Staff 2 (Wellness Nurse) stated the incident had occurred.The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 03/25/25.The facility's failure to carry out medication and treatment orders as prescribed was substantiated.

Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly.A review of the ABST indicated the following:· Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required.· Swing shift: AL 12.73 and MC 4.95 staff required.· Night shift: AL 6.02 and MC 2.4 staff required.A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following:· Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.· Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.· Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required.· The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs.· The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 03/26/25, Staff 1 (Executive Director) stated the following:· Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.· Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift.Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25.The facility's failure to have a fully implemented and updated ABST was substantiated.

Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly.A review of the ABST indicated the following:· Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required.· Swing shift: AL 12.73 and MC 4.95 staff required.· Night shift: AL 6.02 and MC 2.4 staff required.A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following:· Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.· Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.· Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required.· The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs.· The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 03/26/25, Staff 1 (Executive Director) stated the following:· Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.· Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift.Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25.The facility's failure to have a fully implemented and updated ABST was substantiated.

Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly.A review of the ABST indicated the following:· Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required.· Swing shift: AL 12.73 and MC 4.95 staff required.· Night shift: AL 6.02 and MC 2.4 staff required.A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following:· Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.· Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required.· Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required.· The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs.· The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 03/26/25, Staff 1 (Executive Director) stated the following:· Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.· Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift.Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25.The facility's failure to have a fully implemented and updated ABST was substantiated.

The findings of the kitchen inspection, conducted 04/11/24 - 04/12/24, 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 re-visit to the kitchen inspection of 04/12/24, conducted 07/03/24, 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.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
The findings of the second revisit to the kitchen inspection of 04/12/24, conducted 09/16/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observations and interviews, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 04/11/24 at 10:30 am through 12:30 pm, and on 04/12/24 from 11:30 am through 2:00 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine;* Kitchen drains;* Electrical outlets and light switches;* Ceiling fire vents and light fixtures;* Wall behind prep area where knives were stored;* Stove top, oven doors, interior, and exterior;* Industrial mixer and slicer; * Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under and between equipment;* Rack shelving in dry good storage;* Under and behind shelving in dry good storage;* Exterior and interior of reach in refrigerators and freezers;* Interior of food cart; and * Cabinet under sink in memory care kitchenette.b. The following areas were in need of repair:* Section of caulking by dish machine with black debris build up;* Small refrigerator in Memory Care unit with frost build up; * Cabinet under sink in Memory Care unit with damage to wall (hole in concrete) and:* Section of base board missing in Memory Care kitchenette.c. Surface sanitizer strips were not stored properly and were visibly damaged. d. Multiple food items were found not dated when opened. Some items were found past seven days and should have been discarded. Whole shell eggs were found stored above RTE (ready to eat) food items causing potential for cross contamination.e. Multiple containers of bulk dry goods had cups or scoops stored in them.f. Large bucket of used/dirty cooking oil found stored without a cover.g. Some items in refrigerator weren't covered/protected from potential contamination.h. Multiple staff observed coming in kitchen area without washing hands or performing hand hygiene and without hair restrained as required. Two kitchen employees were observed preparing food/handling clean equipment without facial hair restrained.i. Caregiving staff assisting residents with their meals did not have aprons on to prevent possible contamination from their clothing during meals.j. Kitchen staff returned from a break without washing hands. They were also observed to drink from a canned beverage and not wash hands. Cook was observed to wash hands in a prep sink and dry hands on a cloth towel. k. Staff member assisting in dining room during meal service was observed to handle their phone then assist residents with beverages and meals without performing hand hygiene. The hand sanitizer dispenser in the dining room was observed not operational during the survey process. One 04/12/24 At 1:15 pm, the surveyor reviewed with Staff 2 (Dining Service Director) areas in need of cleaning, repair and attention. S/he acknowledged areas. At approximately 1:45 pm, Staff 1 (Executive Director) was informed and acknowledged the of areas in need of correction.
Based on observations and interviews, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 07/03/24 at 12:45 pm through 2:00 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine;* Kitchen drains;* Open stainless steal shelving;* Plate warmer;* Interior of drawers;* Wall behind prep area where knives were stored;* Industrial can opener and housing;* Industrial mixer and slicer; * Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under and between equipment;* Can rack in dry storage;* Exterior and interior of reach in refrigerators and freezers;* Mini refrigerator in Memory care; and * Cabinet under sink in memory care kitchenette.b. The following areas were in need of repair:* Section of caulking by dish machine with black debris build up;* Small refrigerator in Memory Care unit with frost build up; * Cabinet under sink in Memory Care unit with damage to wall (hole in concrete) and:* Section of base board missing in Memory Care kitchenette.c. Plastic coffee mugs noted heavily scored and stained. d. Multiple food items were found not dated when opened/prepared, items stored in refrigerators or freezers not covered or completely sealed. Staff food stored with resident food items. Whole shell eggs were found stored above pre-cooked ham and other food items causing potential for cross contamination.e. Caregiving staff assisting residents with their meals did not have aprons on to prevent possible contamination from their clothing during meals.Staff 1 (Cook and designated Person In Charge at time of revisit) toured with surveyor and acknowledged the above findings.

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

Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 240.

The findings of the on-site investigation, conducted on 09/22/23 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review, conducted during a site visit on 09/22/23, it was determined the facility failed to provide a safe and home-like environment for 1 of 1 sampled resident (#4) whose records were reviewed. Findings include, but are not limited to: In separate interviews on 09/22/23, Staff 1 (Life Enrichment Director) and Staff 2 (Wellness Director) had both stated that Resident 4 was moved to the "assisted living" from the Memory Care (MC) due to another resident in the MC targeting him/her. S/he also stated Resident 4 was moved back to the MC after the other resident had passed away. Staff 2 stated they were unaware of how long the resident was in the "AL" and to his/her knowledge, staffing was not increased to during that time.In a phone interview on 09/26/23, Staff 3 (ED) stated s/he was unaware if there was an assessment done or a new service plan put into place when the resident moved into the "AL". S/he stated they would need to look through the documents.There was no evidence to indicate an assessment or service plan was completed when Resident 4 moved into the AL from the MC in August 2022.A review of progress notes dated August 2022 through April 2023, indicated Resident 4 was moved from the MC to AL on 08/30/22 and was moved back to the MC on 04/05/23. A progress note dated 08/30/22 at 12:44pm indicated that the facility had spoke to Resident 4's family member about trialing a move to the AL side to separate the 2 residents and s/he liked the idea. A progress note dated 02/15/23 at 3:30pm indicated a quarterly assessment was completed on 02/14/23 and that Resident 4 had very poor short-term memory and required frequent re-direction.CS reviewed Resident 4's service plans dated 10/12/21 and 03/03/23 which indicated the following:· "Resident not oriented to place or time"· "Does not have the ability to use or manage a key"· "Very poor short-term memory requiring frequent re-direction"· "Often exit seeks which can cause others in MC to exit seek as well"· "Wanders up and down hallways and will frequently ask where room is, for staff to show where the bathroom is, or when the next meal is"· Both service plans indicated Resident 4's MC room number , even during the time s/he was living in the AL.These findings were shared with Staff 2 and Staff 3 via email on 09/29/23. It was determined the facility failed to provide a safe and home-like environment.Verbal plan of correction: No plan of correction was provided

Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but not limited to:Compliance Specialist reviewed Resident 2's Medication Administration Record (MAR), dated July 2023 through August 2023, and progress notes, doctor's orders, and incident form dated 08/05/23. The documents indicated between 07/23/23-07/29/23 and 08/03/23-08/05/23, Resident 1 was given half a dose of what was ordered for Lorazepam. This occurred 11 times before it was discovered. Progress notes dated 07/03/23 indicated that Resident 1 did not receive his/her 8 pm Tramadol 50 mg tab as ordered. The MT only administered one tab instead of two tabs on 07/01/23-07/02/23. In an interview, Staff 2 (Wellness Director) stated the pharmacy sent two medications, one for scheduled and one for PRN Lorazepam, at the same time and it was read wrong.The findings were reviewed with and acknowledged by Staff 2 on 09/22/23.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: Re-training has been done at MT meetings which occur monthly. Nurse went over the three checks with staff and reminders to check the orders. Facility started labeling the PRN Lorazepam so they don't get the two mixed up.Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:A review of Resident 1's August 2023 Medication Administration Record (MAR) and progress notes indicated on 08/03/23 Resident 1 was given prior PRN Tylenol dose that was discontinued on 08/01/23. Compliance Specialist also reviewed faxes to his/her doctor and to APS dated 08/03/23 regarding the medication error.In an interview, Staff 2 (Wellness Director) stated the medication had "just got discontinued and changed to scheduled instead of PRN" and "the med tech didn't check on the computer before giving".The findings were reviewed with and acknowledged by Staff 2 on 09/22/23.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: Re-training has been done at MT meetings which occur monthly. Nurse went over the three checks with staff and reminders to check the orders.

Based on interview and record review, conducted during a site visit on 09/22/23, it was determined the facility failed to make records available to the Department upon request. Findings include, but are not limited to:In a phone interview on 09/26/23, Staff 3 (ED) stated they would look and see if there was an evaluation or service plan done when Resident 4 was moved from the MC to the AL, and would follow up with the Compliance Specialist (CS). In a phone call on 09/27/23, Staff 3 stated s/he would send the documents by the next morning.Compliance Specialist (CS) was not provided documentation of an assessment or service plan being completed in August 2022 when Resident 4 was moved from the MC to the AL during the onsite visit on 09/22/23. In review of emails sent on 09/26/23, 09/27/23, and 09/29/23 to Staff 3 (ED), the CS requested records of assessments or service plan updates between August 2022 and March 2023 documenting how the facility would be providing the care needed for Resident 4 outside of the MC. The CS did not receive the records as requested.The findings were shared with Staff 2 (Wellness Director) and Staff 3 via email on 09/29/23. It was determined the facility failed to make records available to the Department upon request.Verbal plan of correction: No plan of correction was provided.

The findings of the re-licensure survey, conducted 03/06/23 through 03/08/23, 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, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 03/08/23, conducted 06/13/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure injuries of unknown cause and resident-to-resident altercations were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office as required for 2 of 3 sampled residents (#s 1 and 3) whose incidents were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in February 2021 with diagnoses including dementia, agitation and seizure disorder.Observations of the resident, interviews with staff, and review of the resident's 02/22/23 service plan, 12/31/22 through 03/06/23 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident was noted to be confused, required one staff assistance for ADL care, and needed frequent redirection by staff throughout the day. The resident was vision impaired and hearing impaired. The resident wandered the memory care unit in and out of resident apartments and common areas. The resident required frequent reminders to use his/her walker and had frequent physical and verbal aggression towards staff including hitting, biting, pinching and ramming them with his/her walker. a. Review of the resident's records showed the following:* An incident report dated 12/20/22 indicated the resident was found on the ground and had stated another resident pushed him/her down. Resident 1 had hit his/her head and had complaints of side pain. The incident report indicated the altercation was reported to the local SPD, but no documentation could be located. * An incident report dated 12/31/22 indicated the resident was being assisted to walk by staff when s/he started to fall. Staff intervened to slow the fall. The resident was found to have a skin tear to the right wrist. The investigation was unclear if all interventions were in place and if the staff member or the fall caused the injury. The incident report indicated the incident was reported to the local SPD office, but no documentation could be located. * An incident report dated 01/18/23 indicated the resident reported his/her roommate had grabbed his/her arm "really hard." The resident's roommate confirmed s/he grabbed the resident after Resident 1 bumped the roommate with their walker. The incident report indicated the altercation was reported to the local SPD but no documentation could be located.In an interview on 03/08/23, Staff 1 (ED) indicated she could not locate any further information on the reporting of the injury or resident altercations. Staff 1 checked with the local SPD but they had no record the incidents had been reported to them. Staff 1 reported the three incidents and provided confirmation of the reports prior to survey exit.b. Review of incident investigations for the last 90 days showed 12 incidents had no documented administrator review.In an interview on 03/08/23, Staff 1 indicated she was in the process of getting caught up. Staff 1 stated the policy was for her to review within 24 hours to assist in determination of the need for reporting of any incidents. The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect, reviewed by the administrator and reported to the local SPD as needed was discussed with Staff 1 (ED), Staff 2 (Wellness Nurse), Staff 3 (Wellness Director) and Staff 4 (Operations Specialist) on 03/07/23. The staff acknowledged the findings.2. Resident 3 was admitted to the facility in December 2012 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the resident's 09/22/22 service plan, 11/02/22 through 03/01/23 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident required full assistance of two staff for ADL care and a Hoyer lift for transfers. The resident was confused with short and long term memory impairments. a. An outside provider note dated 01/04/23 indicated the resident had a bruise to the left forearm.There was no investigation completed for the injury of unknown cause. The facility was asked to report the injury of unknown cause to the local SPD office, and confirmation of the report was received prior to exit.b. Review of the resident's completed incident reports for the last 90 days showed two of four had no documented administrator review.The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect, reviewed by the administrator and reported to the local SPD as needed was discussed with Staff 1 (ED), Staff 2 (Wellness Nurse), Staff 3 (Wellness Director) and Staff 4 (Operations Specialist) on 03/07/23. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of a resident's current care needs and provided clear direction to staff for 1 of 3 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in October 2022 with diagnoses including a history of urinary tract infections. S/he was identified during the acuity interview on 03/06/23 as having an indwelling catheter. Resident 2's current service plan, dated 02/21/23, was reviewed and found to lack clear direction to staff in regard to his/her catheter care.In an interview with Staff 2 (Wellness Nurse) on 03/08/23, she reported that catheter care instruction was provided during staff meetings.The need to ensure the service plan provided clear direction to staff on the delivery of services was discussed with Staff 1 (ED), Staff 2 (Wellness Nurse), and Staff 3 (Wellness Director) on 03/08/23. They acknowledged the findings.

Based on interview and record review, it was determined 2 of 2 sampled, newly hired direct care staff (#s 13 and 14) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:The facility's training records were reviewed with Staff 4 (Operations Specialist) on 03/07/23.Staff 13 (Med Tech) hired on 12/22/22 and Staff 14 (CG) hired on 01/31/23 did not have documentation of First Aid and abdominal thrust training completion within the required 30 days of hire.The need to ensure First Aid and abdominal thrust training was completed within 30 days of hire was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Nurse), and Staff 3 (Wellness Director) on 03/08/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:Observations of the facility's assisted living and memory care sections on 03/06/23 and 03/07/23 showed the following areas were in need of cleaning or repair:* Two stains, one black and one red, were noted on the carpet in the common TV area in the assisted living section;* Multiple dining room chairs in both dining rooms had dark stains and food debris on the seats or chair backs;* Furniture in the TV room/common area of the memory care section had large tears to the seat backs of the recliners;* Dark accumulation was noted along baseboards in the dining room, common areas and common bathrooms. Flooring in common bathrooms was missing caulking and pulling apart at the seams in both sections of the facility;* Spills, splatters, dark streaks, scrapes and chunks of missing plaster were noted on walls in the dining rooms, hallways and behind charting stations in both sections of the facility;* Multiple dining room tables in the assisted living and memory care sections had missing laminate along the edges or tabletops with exposed wood/particle board surfaces;* Common bathrooms in both sections of the building had missing and discolored caulking around the toilet and cracked and discolored caulking at the edge of the shower;* Spills and debris were noted in windowsills in both dining rooms and the TV rooms;* A large section of drywall and concrete was missing under the dining room sink in the memory care section;* Multiple cupboards and drawers in both dining rooms had spills, stains or debris;* Two large patch sections to the ceilings of the private dining room and the memory care dining room were observed. Two holes were noted to the patch area in the memory care;* The main laundry had scrapes, dings and chipped plaster along the walls and corners. The washing machines had white/gray accumulation around the lid of the machine and the floor had multiple areas that were cracked, pulling apart at the seams or cracked at the wall edges; and* Rooms 127 and 126 had chips and scrapes to wall edges near doorways. The toilets had missing pieces of caulking as well as brown/black discolored caulking. Flooring was cracked at wall edges, pulling apart at the seams and cracked and discolored at the edge of the shower stalls. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED), Staff 4 (Operational Specialist) and Staff 5 (Maintenance Director) on 03/07/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 231, C 372 and C 513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled, newly hired staff (#s 13, 14 and 15) completed all required pre-service orientation and pre-service dementia training. Findings include, but are not limited to:Staff training records were reviewed on 03/07/23 with Staff 4 (Operations Specialist). Staff 13 (Med Tech) was hired on 12/22/22, Staff 14 (CG) was hired on 01/31/23, and Staff 15 (Life Enrichment Assistant) was hired on 12/16/22. The following were identified:1. There was no documented evidence Staff 13, Staff 14, and Staff 15 completed the required pre-service Infectious Disease Prevention training. 2. There was no documented evidence Staff 13, Staff 14, and Staff 15 completed the required pre-service dementia care training in: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food and fluid, preventing wandering and elopement, and use of a person-centered approach.The need to ensure newly hired staff completed all required orientation and pre-service dementia training before independently providing personal care or other services was reviewed with Staff 4 on 03/07/23 and with Staff 1 (ED), Staff 2 (Wellness Nurse), and Staff 3 (Wellness Director) on 03/08/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 260.

Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height and constructed to reduce the risk of elopement. Findings include, but are not limited to:A tour of the facility's memory care courtyard on 03/06/23 showed two gates within the perimeter fencing that were approximately 5 foot 4 inches in height.A large section of fencing/wall around one side of the courtyard consisted of a short brick wall approximately 2 feet 4 inches in height with a metal fence on top of the wall, that was approximately 4 feet tall. The metal fencing and brick wall had a large gap between them with a wide, flat surface on the top of the wall. The top of the brick wall could easily be stepped onto and stood on by an individual to climb or fall over the 4 foot section of metal fencing.No residents were observed in the courtyard during survey. Observations of the current residents who resided in the memory care unit and interviews with staff showed none of the residents appeared to have the strength, balance or mobility to step up on onto the brick wall at that time. The fencing sections that were less than six feet in height and the wall/fence construction which created a potential elopement risk, was shown to and discussed with Staff 1 (ED), Staff 4 (Operations Specialist) and Staff 5 (Maintenance Director) on 03/07/23. They acknowledged the findings.

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 01/12/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 01/12/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 01/12/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 01/12/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the kitchen inspection, conducted 1/3/23 through 1/4/23, 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. Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:OAR 411-054-0030 Resident Service Meals, Food Sanitation Rules.The facility put an immediate plan of correction in place during the survey and the situations were abated.
The findings of the revisit to the kitchen inspection of 1/3/23, conducted 3/31/23, 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 revisit to the kitchen inspection of 1/3/23, conducted 6/15/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The facilities kitchen was observed in an unsanitary condition, the person in charge lacked knowledge in safe food handling practices which posed an immediate jeopardy situation that could threaten the health, safety, and/or welfare of residents. Findings include, but are not limited to:Observation of the kitchen on 1/3/23 at 11:00 am revealed the following areas.a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine;* Spice shelves;* Juice dispenser;* Kitchen drains;* Electrical outlets and light switches;* Trash cans;* Pipes and flooring underneath the three compartment sink; * Interior and exterior of cabinets and drawers;* Ceiling fire sprinklers, smoke detectors and vents;* Walls throughout kitchen;* Cabinets under the steamtable;* Inside and outside of drawers storing utensils;* Interior and exterior of fryer;* Interior and exterior of microwave;* Stove/grill knobs, doors, interior, exterior;* Wall behind hand wash sink and the sink;* Open shelving throughout kitchen;* Industrial mixer and slicer; * Large can opener;* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges;* Large vent hood above dish machine had a build-up of dust and debris;* Large can goods storage rack;* Rack shelving in dry good storage;* Rack shelving storing equipment and dishes;* Under and behind shelving in dry good storage;* Door thresholds;* Robo coupe machine and supplies;* Large fan next to fridge with multiple layers of dust/dirt and debris;* Exterior and Interior of stand up fridges and freezers;* Probe thermometers;* Shelving with cook books; and* Beverage area in dining room walls and beverage dispensers. b. The following areas were in need of repair:* Counter top in the dining room beverage area had multiple spots were there were chips, cracks, staining and needed repair. The counter area was not a smooth cleanable surface;* Small refrigerator in Memory Care unit with frost build up; and* Cabinet under sink in Memory care unit with damage to wall (hole in concrete).c. Staff 2 (Dining Services Supervisor) was asked about chemical sanitizer test strips. She was unable to locate test strips and could not explain how to use them. Staff 3 (Maintenance director) was responsible for ordering chemicals, but did not know where to locate test strips or the need to test the concentration of the sanitation chemicals. Staff 3 stated, they used to have Eco Lab at the facility who would come frequently to ensure dish machine and 3 compartment sink was working correctly.d. A large package of frozen meat was sitting in standing water for defrosting. Staff 2 was not aware of proper thawing of meat procedures or time tables.e. Multiple dry good items were not dated when opened.f. Cutting boards were heavily scored and/or stained.g. Multiple containers of bulk dry goods had cups or scoops stored in them.h. Plastic mugs/cups with heavy scoring/staining.i. All trash cans in kitchen did not have lids for when not in use.j. Not disposing of used frying oil appropriately.k. Multiple items in freezer and refrigerator not dated or labeled when opened or prepared. l. Multiple items in fridge not covered.m. Shoes and clothing stored on shelves with kitchen equipment.n. During the tour of the kitchen, less than the required amount of dry/staple and perishable foods were observed. Staff 2 stated, she was new and was trying to figure out ordering food supplies. Staff 3 validated that he had never seen the freezer and dry storage that empty. o. During lunch tray service, staff 2 was observed touching potentially contaminated items with her gloved hands and then proceed to prepare ready to eat sandwiches. The Surveyor alerted staff 2 of the need to sanitize hands and change gloves before continuing preparing ready to eat foods. Staff 2 acknowledged the surveyor, but continued with task without changing gloves. The Surveyor requested Staff 2 to complete proper hand hygiene.p. Staff 2 was unable to demonstrate required knowledge for thawing, cooling, proper cooking temperatures, proper reheating temperatures, proper holding temperatures, signs and symptoms of food borne illness, proper sanitation of surfaces/pots/pans. She indicated that she had her food handlers card, but had not finished her Relias training. She stated, she had a binder to refer too but had not had the time to complete. Staff 2 verified, she had not been thoroughly trained and did not have any prior food service director or industrial cooking experience. q. Multiple staff observed coming in kitchen area without washing hands or performing hand hygiene.r. Memory care unit kitchenette area observed with food splatters on walls by and behind counter. Items in fridge not labeled or dated, fan with large accumulation of dust/debris, and shelving with drips/food splatters in lower cabinets. At approximately 12:08 pm on 01/03/23, the surveyor contacted the Community Based Care Supervisor and shared concerns about the unsanitary condition of the kitchen, the inadequate knowledge of person in charge and the lack of appropriate food supply. A decision was made to close the kitchen until the unsanitary and unsafe condition was rectified, and a long term plan was put in place.In an interview on 01/03/23 at 12:15 pm, Staff 4 (Wellness Nurse) and Staff 3 (Maintenance director) and were informed by the Surveyor that the kitchen would be shut down. They were instructed to submit an immediate plan of correction to address the unsanitary and unsafe conditions. At that time, no Executive Director was available as the former Executive Director had recently resigned. At 12:44 pm, Staff 1 (Corporate Operations Specialist) was informed via phone the concerns identified and the need for plan of correction. Staff 1 acknowledged concerns and a plan to suspend kitchen operations until a qualified person in charge was there and kitchen sanitation was started and improved.At 3:46 pm, Staff 5 (DDS Operations Specialist) arrived at the facility to oversee kitchen cleaning, food ordering and provide training to staff 2. During an interview, Staff 5 was able to verbally demonstrate adequate knowledge of safe food handling practices. The dinner meal would be brought in from outside vendor while kitchen was being cleaned. The facility submitted a plan of correction on 01/03/2 at 4:00 pm, which was approved by the Surveyor. On 01/03/23 at 4:20 pm, the kitchen areas were being cleaned with significant progress. The Immediate Jeopardy situation at that point in time was abated and the kitchen was able to resume service for breakfast the next day. On 1/4/23 at 9 am, the Surveyor re-inspected the kitchen and observed continued improvement in the above areas.
Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observation of the kitchen on 3/31/23 at 10:30 am revealed the following: a. An accumulation of food spills, splatters, and loose dried food debris was visible on the following:* Interior of microwave; and* Industrial mixer and slicer. b. Plastic mugs/cups continued with heavy scoring/staining.c. Cleaning chemicals were observed stored directly over where clean kitchen rags were stored causing potential for contamination.d. During lunch tray service on 3/31/23 and again on 4/3/23, kitchen staff were observed touching potentially contaminated items with their gloved hands and then proceeded to touch/handle ready to eat items. e. The memory care kitchen was observed and 2 containers of juice were found on the counter and were not covered. An additional 2 containers of juice were stored in the small refrigerator not covered. The small refrigerator had an accumulation of ice in the freezer space. Drips and spills of food items were found in the interior of the small fridge. Kitchenette shelving was observed with drips/food splatters in lower cabinets and standing water found in upper cabinets and under the sink. Cups were noted to be stored wet and had not had sufficient time to dry as required. On 3/31/23 at 11:17 am Staff 1 (Executive Director) was contacted via telephone regarding training and QA (Quality Assurance) audits per submitted plan of correction. Staff 1 indicated that s/he was currently overseeing the kitchen as the facility's DSD had just resigned. Staff 1 provided surveyor with March's QA audits and indicated that s/he walked the kitchen daily to ensure items were addressed.On 4/3/23, training records were reviewed and Staff 4 (Cook) and Staff 5 (Cook) did not have documentation they had received/completed specific training on kitchen sanitation or job duties for cook or dietary server. Interview with Staff 3 verified no training documentation for those employees were found. The facility could not provide documented evidence that the employees preparing food for the residents had received appropriate training. The findings of the main kitchen, MCC kitchen and lack of training was discussed with Staff 1 on 04/03/23 and s/he acknowledged the findings.

Based on interview, observation and review of documentation, 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 C240.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 240.
Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

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 10/20/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review, it was confirmed that the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. Findings include:In review of the facility's policy and procedures for reporting to APS and incident reports from August-October 2022 for Resident #1, it was determined that the facility did not notify APS for multiple resident to resident altercations and falls with injury. The above information was shared with Staff #1 on 10/21/22, who acknowledged the findings.In an interview on 10/20/22, Staff #1 stated that because of short staffing, the Wellness director and Wellness Coordinator have been filling in care staff shifts, and they have not been getting to the incident reports and reporting timely. Plan of correction:Re-training to staff regarding APS reporting requirements and what information needs to be provided. Hiring additional staff so that the Wellness Director can perform their job duties timely.Based on interview and record review, it was confirmed that the facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent reoccurrence of abuse. Findings include:In review of the facility ' s policy and procedures for Incident Reports and Abuse Reporting, progress notes, and incident reports from August-October 2022 for Resident #1, it was determined that the Wellness Director, Nurse, and Administrator are not reviewing the investigation, completing the review and assessment, or completing the administrator review per their policy. Follow up with staff regarding training, interventions being put in place, updating the service plans, and notifying APS of any abuse/suspected abuse and neglect is not being completed or documented. Most of the incident reports reviewed are still " In Progress " under the status.The above information was shared with Staff #2 on 10/21/22, who acknowledged the findings.In an interview on 10/21/22, Staff #1 stated that because of short staffing, management has been filling in for care staff, and they have not been getting to the incident reports to review and complete or report timely to APS. Plan of correction:Re-training to staff regarding incident reports, internal investigation process, and APS reporting requirements. Hiring additional staff.

Based on interview, observation, and record review, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include:In review of Resident #1-4 ' s Service Plans on 10/20/22, it was determined that they are not being updated quarterly. Three out of the four service plans haven ' t been updated since October 2021. Resident #1 has had multiple falls and resident to resident altercations since August 2022, which have not been updated on the service plan.On 10/20/22, CS observed that the service plans available to staff in the binders are not updated.The above information was shared with Staff #1-2 on 10/20/22, who acknowledged the findings.In an interview with Staff #2 on 10/20/22, they stated that the facility is behind on their quarterly updates. Their wellness director is usually responsible for updating the service plans, however, due to short staffing, they have been working on the floor as care staff and the service plans have not been updated.Plan of correction:Determine how many residents need quarterly updates. Facility will be hiring additional staff so that the wellness director will be free to working on their job duties assigned.

Based on interview and record review, it was confirmed that the facility failed to keep an accurate medication administration record (MAR) of all medications. Findings include:Review of Resident #1s medication administration records (MARs) and progress notes for September and October 2022 showed multiple missed entries on the MAR for multiple medications. No staff initials or notes regarding whether or not the medication was given.In interviews on 10/20/22, Staff #4 stated that they should be documenting the medications as they are given in the MAR. If they are refused or not given for any reason, they still initial and make a note/reason for not being given. The above information was shared with Staff #2 on 10/20/22, who acknowledged the findings.Plan of correction:Facility is in contact with Consonus Pharmacy to provide a med tech pass audit and retraining for staff.

Based on interview, observation, and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:Review of staffing schedules for September- October 2022, posted staffing plan, Acuity Based Staffing Tool (ABST), and service plans and progress notes for Resident #1. The wellness coordinator and wellness director are filling in as care staff regularly for call outs/staffing needs. The posted staffing plan shows that Days and Swing shifts are to have 3 care staff and 1 med tech (1 in memory care, 2 in assisted, and a shared med tech), and the NOC shift has 2 care staff and 1 med tech (1 in memory care, 1 in assisted, and shared med tech). The ABST provides the following weekly hours needed: Day 89.25, Eve 326.55, and NOC 373.7. The facility is not staffing per the ABST and the ABST does not match the posted staffing plan. Resident #1s progress notes and incident reports from January-March 2022 show multiple falls and resident to resident altercations, however, the service plans and temporary service plans have minimal interventions and instructions following these incidents. An interim service plan dated 10/05/22 states to be mindful of the resident ' s whereabouts at all times. If there is only 1 staff in the memory care, this is not always possible.On 10/20/22 compliance specialist (CS) observed that Resident #1s service plan in the memory care binder has not been updated quarterly and is dated 10/04/21. CS observed Staff #3 assisting Resident #1 in their room while Staff #4 was passing meds in the dining room. CS observed 1 care staff in the memory care, 2 care staff in the assisted, and 1 med tech going between the two during onsite visit on 10/20/22.The above information was shared with staff #2 on 10/24/22.In interviews on 10/20/22, Staff #1 stated that they have had some issues with staffing and are in the process of hiring. They stated that there are 2 2-person transfers in the assisted living and 2 in the memory care. They only have 1 care staff in the memory care and if they need assistance, they will call for the med tech or other care staff from the assisted side. The wellness director and wellness coordinator are both out right now because they are covering on NOC shift this evening. Staff #3-4 stated that sometimes there is enough staff. They are not always able to get laundry done. Toileting and showers are getting done but sometimes residents will have to wait. There is only 1 care staff in the memory care and the med tech works on both sides. If they need assistance with a transfer they will call for assistance. During the day shift, management will come help out if they are busy.Plan of Correction:Hiring new staff, staffing per the ABST and updating the posted staffing plan. Hiring an additional wellness coordinator so that the wellness director can focus on their job duties such as service plan updates, incident report follow up, medication oversight.

Based on interview, observation and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:Review of staffing schedules for September and October 2022, posted staffing plan, ABST, and service plan for Resident #1. The ABST provides the following weekly hours needed: Day 89.25, Eve 326.55, and NOC 373.7. The posted staffing plan shows that Days and Swing shifts are to have 3 care staff and 1 med tech (1 in memory care, 2 in assisted, and a shared med tech), and the NOC shift has 2 care staff and 1 med tech (1 in memory care, 1 in assisted, and shared med tech). The ABST and posted staffing plan do not match. Resident #1s service plan is not accurately reflected in the ABST. The ABST is showing that showers only take 5 minutes, when they report that it takes an average of 30 minutes per shower. Specific housekeeping or laundry is documented as 7 minutes on average, however, on the ABST it is being counted as 1 minute per occurrence. Resident #1-4 all have service plans that are not updated quarterly, so the ABST is also not updated quarterly with changes.CS observed that the facility is not staffing per the ABST on 10/20/22. The posted staffing plan has not been updated with the current staffing levels from the ABST.The above information was shared with Staff #1 on 10/24/22, who acknowledged the findings.In an interview on 10/20/22, Staff #2 stated that the facility is using their own ABST. They just recently updated it. Staff #2 was unable to explain the ABST and how the staffing hours are calculated. Staff #2 stated they would need to check with home office as they are working on the data/calculation errors.Plan of Correction: The facility is hiring more staff, service plans will be worked on to get updated, they will assess the ABST and make sure information is correctly entered as well as fix any calculation issues. The posted staffing plan with be updated to match the ABST.