Miramont Pointe

Based on interview and record review, conducted during a site visit on 06/10/24 and 06/11/24, it was confirmed the facility failed to review the initial service plan within 30 days of move-in for 2 of 2 sampled residents (#s 5 and 6). Findings include, but are not limited to: Resident 5's initial service plan was dated 07/13/23. Resident 5's next service plan was dated 09/04/23. Resident 6's initial service plan was dated 07/13/23. Resident 6's next service plan was dated 09/04/23. During an interview on 06/13/24, Staff 12 (Administrator) stated when the event occurred, they did not have a Resident Care Coordinator (RCC) and there was a lapse in the responsibility for service plans. The facility failed to review the initial service plan within 30 days of move-in. The findings were reviewed with and acknowledged by Staff 12 on 06/13/24. Verbal plan of correction: The facility now has two fully trained RCCs who are responsible for coordinating all service plan reviews.

Based on observation, interview and record review, conducted during a site visit on 06/10/24 and 06/11/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 1 of 1 sampled resident (#1). Findings include, but are not limited to: During an observation and interview on 06/11/24, Resident 1 was observed to engage his/her call pendant. It took staff 13 minutes to respond to the call light. During the interview, Resident 1 stated s/he had been left on the toilet many times and it frequently took staff over 30 minutes to respond to call pendant and that meal times, staff breaks and shift changes were the worst. Resident 1's call light logs for August 2023 were requested, but were unavailable. Call light logs for 06/01/24 through 06/11/24 revealed 10 instances in which Resident 1 waited for more than 15 minutes for assistance. Three of those ten times were greater than 30 minutes. It was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The findings were reviewed with and acknowledged by Staff 12 (Administrator) on 06/13/24. Verbal plan of Correction: Resident Care Coordinators will run call light log reports for their respective residents no less than weekly. Administrator will review these weekly and follow up with residents and staff on how to reduce wait times.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents due to staffing levels on the overnight shift. Findings include, but are not limited to: At survey entrance on 04/22/24, the facility had 14 residents who resided in the secured memory care unit on floor one of the building, and 125 residents who resided on floors two through eight, for a total of 149 residents on eight floors. During an interview on 04/23/24, Staff 1 (ED) stated the facility currently staffed the overnight shift as follows: * One CG for the locked memory care unit on floor one; * One CG for floors two through eight; and * One MT who floated between the locked memory care unit and floors two through eight. When the CG in the memory care unit took breaks, including a 30-minute lunch break, the float MT stayed in the memory care unit. This left only one staff member to assist 125 residents on floors two through eight. The facility had one resident who required two-person assistance for transfers and incontinence care, and did require assistance at night, as identified in his/her service plan. The resident resided on the second floor. The current staffing plan did not allow for his/her care needs to be met at all times. Additionally, when that resident did get care assistance, that meant no other staff was available to assist with any medication needs, provide additional memory care unit support, or address the needs of the other 124 residents on floors two through eight. When asked whether the current staffing plan allowed for safe evacuation of residents in the case of an emergency, Staff 1 stated they did not have any documentation of evacuation drills or documentation of how staff would ensure the health and safety of residents in the case of an emergency which required evacuation. On 04/25/24, the survey team requested two additional caregivers be added to the overnight shift for floors two through eight. The facility agreed, and provided documentation as to how they would meet this staffing plan. The need for the facility to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents, especially as related to sufficient staffing on the overnight shift, was reviewed with Staff 1, Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing/RN) on 04/25/24. They acknowledged the findings.

1. Facility has trained the NOC receptionist as a caregiver. Facility has also added 1 additional direct care staff to the NOC shift. There will be 5 total staff onsite overnight, able to aid in an evacuation if needed. Floors 1 and 2 will have designated one staff person each. 2. Facility has implemented additional staff support overnight by way of 1 additional direct care staff and training the NOC receptionist on caregiving duties. These additions are reflected in facility staffing plan. 3. Staffing plan will be evaluated following ABST updates no less than quarterly for for move ins, changes of condition and acuity changes. 4. The Executive Director or Designee.

2. Resident 6 was admitted to the facility in 02/2023 with diagnoses including Alzheimer's dementia. The resident's 03/01/24 through 04/22/24 MARs and physician's orders were reviewed and identified the following: Resident 6 had physician's orders: *03/06/24: Tylenol 325 mg, take 2 tabs (650 mg) four times a day, not to exceed 3,500 mg daily, and the order was changed as follows: *04/16/24: Tylenol 500 mg, take 2 tabs (1000mg) four times a day. A review of the MARs showed from 03/01/24 through 04/22/24 the resident was receiving Tylenol 500 mg, 2 tabs (1000 mg) four times a day for a total of 4,000 mg per day. Interviews with Staff 3 (Director of Nursing) and Staff 18 (RN) showed the MAR was inaccurate. The resident had been receiving Tylenol 325 mg - 2 tabs (650 mg) four times a day on 03/01/24 through 04/16/24 when the physician changed the order to Tylenol 500 mg (1000 mg) four times a day. Staff 3 and Staff 18 determined the order change had been entered into the electronic MAR system incorrectly on 04/16/24. The MAR did not reflect accurately the correct dosage had been administered 03/01/24 through 04/16/24. The need to ensure resident MARs were accurate was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing/RN) on 04/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate related to order transcription and order changes for 2 of 5 sampled residents (#s 2 and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 09/2012 with diagnoses including bladder cancer and major depressive disorder. A review of Resident 2's 04/01/24 through 04/21/24 MAR, physician's orders, and Progress Notes dated 01/01/24 through 04/21/24 identified the following: A physician's order dated 04/03/24 stated, "Dermaseptin to buttocks area. After peri care at each brief change, apply dermaseptin [sic] cream to buttocks area. You do not need to completely remove previous layer of barrier cream as it is meant to build up a barrier to moisture over several applications." The order was incorrectly transcribed on the MAR as, " ...After peri care at each brief change, apply dermaseptin cream to buttocks area; remove the previous layer of barrier cream ..." The need to ensure MARs were accurate related to transcribed physician's orders was discussed with Staff 1 (ED), Staff 3 (Director of Nursing/RN) and Staff 21 (Quality Coordinator) on 04/26/24. They acknowledged the findings.

1. MAR for Resident 2 has been corrected to indicate the order as prescribed. MAR of Resident 6 has been corrected to indicate accurate start and end dates as precribed for different dosages. 2. Facility has implemented a multiple-step process for new medication order approvals. This process will now require a med tech, RCC and nurse to review the order both as prescribed and as it's transcribed to assure MAR accuracy. Additionally, the staff responsible for the order approval process have been trained on this process. 3. MARs will be reviewed quarterly. 4. Resident Care Coordinator and Director of Nursing.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to: On 04/23/24, the facility identified their current staffing level during the overnight shift to be: * One CG for the locked memory care unit on floor one; * One CG for floors two through eight; and * One MT who floated between the locked memory care unit and floors two through eight. This was not sufficient staff to meet the 24-hour scheduled and unscheduled needs of each resident and to ensure a minimum of two direct care staff were available at all times for a resident who required two person care assistance. The need to have a sufficient number of staff in each building to meet all scheduled and unscheduled needs of residents on the overnight shift, including a minimum of two direct care staff available at all times for a resident who required two direct care staff, was discussed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing) on 04/24/24 and 04/25/25. They acknowledged the findings. Refer to C 160.

1. Facility has trained the NOC receptionist as a caregiver. Facility has also added 1 additional direct care staff to the NOC shift. There will be 5 total staff onsite overnight, able to aid in an evacuation if needed. Floors 1 and 2 will have designated one staff person each. 2. Facility has implemented additional staff support overnight by way of 1 additional direct care staff and training the NOC receptionist on caregiving duties. These additions are reflected in facility staffing plan. 3. Staffing plan will be evaluated following ABST updates no less than quarterly for for move ins, changes of condition and acuity changes. 4. The Executive Director or Designee.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) to specify the total number of minutes required to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to: The ABST was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN) and Staff 3 (Director of Nursing/RN) on 04/23/24 and 04/24/24. The facility had a census of 149 residents when the survey team entered on 04/22/24. The facility consisted of two segregated areas: * Floor one, a secured memory care unit with 14 residents; and * Floors two through eight with 125 residents. During the acuity interview on 04/22/24, staff identified one resident on floors two through eight who required two direct care staff to assist him/her. Residents on floors four through eight would need to descend stairs to evacuate the facility in the case of an emergency event in which the elevators would be inoperable. During an interview on 04/25/24, Staff 1 and Staff 2 stated they were not currently accounting for evacuation needs, an unscheduled need, on the ABST. The current ABST did not account for staffing two segregated areas and having two direct care staff available at all times for residents who required two direct care to assist them. The need to ensure the ABST specified the total number of minutes required to the meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2 and Staff 3 on 04/25/24. They acknowledged the findings.

1. Facility has trained the NOC receptionist as a caregiver. Facility has also added 1 additional direct care staff to the NOC shift. There will be 5 total staff onsite overnight, able to aid in an evacuation if needed. Floors 1 and 2 will have designated one staff person each. 2. Facility has implemented additional staff support overnight by way of 1 additional direct care staff and training the NOC receptionist on caregiving duties. These additions are reflected in facility staffing plan. 3. Staffing plan will be evaluated following ABST updates no less than quarterly for for move ins, changes of condition and acuity changes. 4. The Executive Director or Designee.

Based on interview and record review, it was determined the facility failed to ensure written fire drill records were kept that included all required information per the Oregon Fire Code (OFC) and have documented evidence fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: On 04/25/24, fire and life safety records dated 12/12/23 through 03/13/24 were reviewed. Fire drill documentation did not 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 drill; * Evacuation time-period needed; and * Number of occupants evacuated. Documentation of fire and life safety training for staff was provided, however the documentation did not include information on the date of the training and staff members who attended or participated in the training. The need to ensure fire drill documentation included required components and documented evidence staff training was completed on alternating months was discussed with Staff 1 (ED), Staff 2 (Regional Director Health Services/RN), Staff 6 (Maintenance Director), and Staff 23 (Maintenance Assistant) on 04/25/24. They acknowledged the findings.

1) Fire drills and Staff Fire & Life safety trainings will be completed on alternating months and documented in accordance with OFC required drill components, including the date of the training and staff members who attended or participated in the training. 2) Scheduled monthly drills will be completed following new fire drill form that contains required elements, adding: Escape route used; Problems encountered, comments relating to residents who resisted or failed to participate in the drill; Evacuation time-period needed; and Number of occupants evacuated.   3) Fire drills and Fire & Life safety training will be reviewed monthly for completion. 4) Maintenance Director, Executive Director or designee.

Based on observation and interview, it was determined the facility failed to ensure the design of an RCF emphasized a residential appearance while retaining the features required to support special resident needs relating to handrails installed on one or both sides of resident-use corridors. Findings include, but are not limited to: During a tour of the RCF on 04/23/24 at 09:20 am the following was identified: Approximately 40 feet of corridor on the third floor separating the swimming pool on one side, and the beauty salon on the other side, did not include handrails on either side of the corridor. The need to ensure handrails were installed on one or both sides of resident-use corridors was discussed with Staff 1 (Executive Director) on 04/25/24. He acknowledged the findings. No further information was provided.

1. Facility will install a handrail on one side of the relevant corridor and in compliance with OAR. 2. Facility will ensure the handrail is installed as required by OAR. 3. This will be evaluated upon installation, after which will not require ongoing evaluation. 4. Maintenance Director, Executive Director or designee.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: During a tour of the facility on 04/23/24 at 9:20 am, the following was identified: a. Common areas in the RCF portion of the facility: * Handrails throughout the facility were worn and had exposed wood, especially on the fourth floor; * Dust was accumulated on the wall behind the dryers in the laundry rooms on the fourth, fifth, and six floors; * Numerous fluorescent light fixtures in the facility stairwells were lacking fixture covers; * Gap in drywall under the air duct in the commercial laundry room; and * Numerous ceiling vent grates were covered with dust. b. Dining area in MCC part of the building: * Various light fixtures with dead bugs inside; * Finish on wood around dishwasher worn off; and * Worn and damaged cabinet frames and doors and missing drawers in the kitchen island cabinets. c. Building Exterior: * The area outside the trash dumpster contained old furniture, appliances, and other discarded items; * The exterior building wall near the trash dumpster had a large, L-shaped hole; * The meditation garden area dirty with rusty firepit and old, soiled furniture; * Third-floor patio grill and grill grates dirty, rusted, and covered with baked-on grease; and * Pan with collected grease on ground next to grill on patio. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Executive Director) and Staff 6 (Maintenance Director) on 04/23/24, 04/24/24, and 04/25/24. They acknowledged the findings. No further information was provided.

1. Findings have been addressed, cleaned or repaired. Old appliances, refuse items and existing patio grills have been discarded. 2. The maintenance walkthrough checklist has been updated to include monitoring of finding areas. These areas will be monitored for compliance on a routine basis to ensure the environment is maintained, clean and in good repair. 3. Maintanence will conduct quarterly walkthrough inspections. 4. Maintenance Director, Executive Director or designee.

Based on observation and interview, it was determined the facility failed to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exited the facility. Findings include, but are not limited to: The building was toured on 04/23/24 at 09:20 am. Observations and interviews with staff confirmed RCF residents were able to exit the facility from a door on the second floor adjacent to the elevator and which led to an employee entrance. The route did not have a functioning alarm or other system to alert staff when residents exited the building. In the MCC portion of the facility, two doors leading from the dining area to the secured courtyard were observed without a functioning alarm system to alert staff when a resident exited the building into the courtyard. On 04/25/24, Staff 1 (Executive Director) demonstrated a temporary system installed on 04/24/24 in the MCC dining area that included audible door chimes, although the chimes were not loud enough to be widely audible. During the survey, staff ordered a pager-based door alarm system to be installed as a replacement. The need to ensure the facility had an alarm or other acceptable system to alert staff when residents exited the RCF and MCC was discussed with Staff 1 and Staff 2 (Regional Director of Health Services/RN) on 04/25/24. They acknowledged the findings. No further information was provided.

1. Doors without proper notification systems installed have been identified. 2. Door notification transmitters have been added to the loading dock and memory care courtyard doors to notify staff when opened. 3. Door notification system will be evaluated quarterly as part of maintenance inspections. 4. Maintenance Director, Executive Director or designee.

Concerns were identified and the facility was provided with technical assistance in the following area: H 1515: OAR 411-004-0020 (2) Physical Setting: Individual Accessible (b) The setting is physically accessible to an individual.

Based on 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 160, C 360, C 361, C 420, C 511, C 513, C 555.

Refer to C 160, C 360, C 361, C 420, C 511, C 513, C 555.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 9, 11, 12 and 22) completed all required pre-service orientation and dementia training topics; 3 of 3 newly-hired direct care staff (#s 9, 11 and 12) completed all additional pre-service dementia training topics; and 2 of 2 long term non-care staff (#s 5 and 24) completed annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 04/23/24 through 04/25/24. 1. There was no documented evidence Staff 11 (MT), hired 12/24/23, Staff 12 (CG), hired 03/04/24, Staff 9 (CG), hired 03/11/24 and Staff 22 (Housekeeping Assistant), hired 03/04/24, completed one or more of the following pre-service orientation and dementia training topics: * Infectious Disease Prevention; * 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/fluids, preventing wandering, and use of a person-centered approach. 2. There was no documented evidence Staff 9, Staff 11 and Staff 12 completed one or more of the following pre-service dementia training topics required of direct care staff: * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and * Use of supportive devices with restraining qualities in memory care communities. 3. There was no documented evidence Staff 5 (Activities Director), hired 07/12/21, and Staff 24 (Assistant Chef), hired 06/04/14, completed the required annual infectious disease training. The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules was discussed with Staff 1 (ED), Staff 2 (Regional Director of Health Services/RN), Staff 3 (Director of Nursing/RN), Staff 19 (RCC) and Staff 21 (Quality Coordinator) on 04/25/24. They acknowledged the findings.

1. Training plans have been audited and missing elements identified. Existing employees have been assigned the missing courses. 2. Training plans have been adjusted to include courses that provide required training elements in accordance with regulation. 3. Staff training will be reviewed on a monthly basis to assure completion. 4. Human Resources Generalist, Executive Director or designee.

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 310.

Refer to C310

Based on observation and interview, it was determined the facility failed to ensure access to secured outdoor space and walkways allowed residents to enter and return without staff assistance. Findings include, but are not limited to: During a tour of the RCF on 04/23/24 at 09:20 am the following was identified: In the MCC portion of the facility, two doors leading from the dining area to the secured courtyard were observed to be difficult for residents to open from the courtyard side, requiring the assistance of staff to allow residents to return to the dining area. The need to ensure access to secured outdoor space and walkways allowed residents to enter and return without staff assistance was discussed with Staff 6 (Maintenance Director) on 04/23/24 and Staff 1 (Executive Director) on 04/25/24. They acknowledged the findings. No further information was provided.

1. The door has been inspected and was found easy to use at time of inspection. 2. The door handle has been lubricated as preventative maintenance and to promote ease of use. 3. The ease of use will be evaluated quarterly as part of maintenance walk through inspections. 4. Maintenance Director, Executive Director or designee.

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition, and outdoor furniture was of sufficient weight, stability, and design not to aid in elopement. Findings include, but are not limited to: During a tour of the RCF on 04/23/24 at 09:20 am the following was identified: The fence surrounding the secured courtyard was missing one board and had numerous other smaller gaps, the gate separating the secured courtyard from the exterior area was only five feet, eight inches high, and the secured courtyard contained various chairs that could aid in resident elopement. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition, and outdoor furniture was of sufficient weight, stability, and design not to aid in elopement was discussed with Staff 6 (Maintenance Director) on 04/23/24, and Staff 1 (Executive Director) and Staff 2 (Regional Director of Health Services, RN) on 04/24/24 and 04/25/24. They acknowledged the findings. No further information was provided.

1. The Memory Care Courtyard fence boards were secured and gate replaced on 4/24/24. The outdoor furniture in question was removed from the area to be further assessed for sufficient weight on 4/23/2024. 2. Maintenance has been trained on the importance of security as it pertains to the Memory Care fence and outdoor furnings. 3. The Memory Care Fence and furnishings will be evaluated quarterly. 4. Maintenance Director, Executive Director or Designee.

The findings of the re-licensure survey, conducted 04/22/24 through 04/26/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 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 re-visit to the re-licensure survey of 04/26/24, conducted on 10/30/24, 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 and interview, it was determined the facility failed to ensure kitchen practice and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 10/19/23 at 11:00 am, the facility kitchen was observed and the following areas were in need of cleaning: a. Food spills, splatters, debris, dust and/or black matter were observed on or underneath the following: * The outside of food bin containers holding oatmeal, panko, flour, rice, powdered sugar and brown sugar;   * The lower shelves throughout the entire kitchen, areas included the steam table, prep counters, Hobart mixer, shelf with large cooking pans and tubs, counter holding blender and waffle maker; * The ceiling and vent in the area near the dishwashing room; * The ceiling vent outside of dry storage; * The wall above the dish racks; * The wall behind the spray nozzle in the dishwashing room; * The walls beneath dishwashing counter; * Fan in dishwashing room; * The flooring throughout entire kitchen; * The equipment throughout the kitchen including refrigerators on the service line, ice machine, deep fat fryer, drawer refrigerator, hot box, stove, grill, steamer and convection oven; * The interior of refrigerators on the service line; * The walls behind the stove/grill and the stand alone freezers; and * The fan on wall in the dishwashing room. b. Cutting boards on service line refrigerators had gouges and dark matter build up, creating uncleanable surfaces. c. Missing cove base tiles in the area of the dishwashing room and chemical storage area were in need of repair. d. Improper food storage included: * An open box of blueberries garden burgers in the freezer and an uncovered pan of unidentified food product;   * Dry storage: scoops/cups were in bins of panko crumbs, flour, rice; and * Two tubs of ice cream were uncovered in the freezer in the beverage station area. The areas of concern were discussed with Staff 1 (Executive Director) and Staff 2 (Culinary Director) on 10/19/23. The findings were acknowledged.

1) The kitchen has been deep cleaned. Vents removed and cleaned as well as the fan in dishwashing area. Maintenance is working with outside contractor to replace broken covebase tiles. 2) The Culinary Director has implemented a routine cleaning schedule for daily and weekly cleaning tasks. Training provided to kitchen staff on this requirement to prevent this reoccurrence. 3) Kitchen walk-throughs to ensure cleaning routine is completed will take place weekly for 60 days, then monthly to ensure cleaning routine still in place. 4) ED or designee will be responsible to monitor these areas for completion and future follow through.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The kitchen was toured on 12/28/23 at 12:44 pm. a. Food spills, splatters, debris, dust and/or black matter were observed on or underneath the following: * Hobart mixer including cart and equipment in the bin that was stored on the shelf underneath the mixer; * Shelf underneath the prep table where the cutting boards were stored; * The meat slicer and stainless steel cart; and * Multiple service carts were not cleaned and sanitized after use. b. The following areas required repair: * The ceiling and vent in the area near the dishwashing room was discolored brown and the vent was falling down; * The ceiling vent outside of the dry storage was discolored brown; * The wall behind the sink with a spray nozzle in the dishwashing room, the walls above and beneath the dishwashing counter had black and brown matter buildup; * Multiple small holes in the wall above the spray nozzle sink, dishwashing area and the wall above the hand wash sink in the dishwashing area; * Multiple areas of broken tile, including cove base tiles and missing grout around the cove base tiles; * Cutting boards on the service line above the salad refrigerator and chef refrigerator had gouges and dark matter build up, creating uncleanable surfaces; and * The hand wash sink (located at the entrance of the kitchen and in between a food warmer and a prep table that housed the waffle maker) didn't have a splash guard. c. Improper food storage included: * Open bag of garden burgers, pepperoni and a box of open biscuits in the walk-in freezer; * Open bag of cranberries and leftover chili in the walk-in refrigerator; * Multiple food products in the walk-in refrigerator and the salad line refrigerator were not labeled and dated, including onions, mixed fresh cut vegetables, fresh cut cucumbers, breakfast patties and links, shredded hashbrowns, and an unidentified sauce mixture; * Scoops/cups were in bins of sugar; and * Open packages of chocolate chips, coconut flakes, pancake mix, rice and potato chips. The kitchen was toured and the areas requiring cleaning or repair was discussed with Staff 1 (ED), Staff 2 (Dining Services Director) and Staff 3 (Dining Room Supervisor) on 12/28/23. They acknowledged the findings.

1) Food splatters, debris and dust have been cleaned. Ceiling vents have been cleaned and replaced. Holes in wall have been filled or FRP panels replaced. Cutting boards have been replaced. Spash guards have been installed on handwashing sinks. Opened food items have been removed, scoops have been removed from bins, open packages have been thrown away. Flooring issues have been addressed. 2) Training has been held with dietary staff to address the findings. Cleaning checklists have been implemented and staff trained on how to use. 3) Walk-throughs of the kitchen and cleaning checklist validation will be completed 5x per week for 1 month and once weekly after 1 month. 4) This will be overseen by the Executive Director and/or designee.

Based on observation 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 C 240.

See C240.

Based on observation and interview, 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.

See C240

Based on observation and interview, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240 and Z142.

See C240

The findings of the kitchen inspection, conducted 10/19/23, 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 Service - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 10/19/23, conducted 12/28/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 10/19/23, conducted 03/29/24, 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, during a site visit conducted on 06/14/23, 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 the reoccurrence of abuse for 1 of 1 sampled resident (# 2). Findings include, but not limited to: During an interview on 06/13/23  Staff 1 (Executive Director) stated, he completed a "grievance form" form when the money was reported stolen. He stated this was not what the facility typically  used to investigate abuse or neglect. The facility reported that matter to the police, but did not report to APS. He felt it was "too murky" to consider it as abuse or neglect and warrant an investigation because the resident had left the facility with their purse for outside appointments. Staff 1 explained they have a process in Service Minder (care-planning platform) called risk management for abuse and neglect investigations. He stated they interviewed staff, family, and Resident 2 but did not document the interviews. No documentation of an investigation was provided by the facility other than a grievance form dated 02/15/23. The bottom of the form had instructions to "Attach investigative process, copies of in services held and attendance sheet" though no attachments were included. The findings were reviewed with and acknowledged by Staff 1 on 06/14/23. The facility failed to promptly investigate a report of stolen property of abuse and suspected abuse, and take measures necessary to protect residents and prevent the reoccurrence. Verbal plan of correction: A copy of the ODHS abuse investigation and reporting guide was provided by email on 06/15/23. Staff 1 and Staff 2 (Director of Nursing) to review and will investigate and document investigations for any claims of financial abuse and exploitation in addition to their normal risk management form or other forms of alleged abuse and neglect.

Based on observation, interview and record review, during a site visit conducted on 06/14/23, it was confirmed the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents for 1 of 1 sampled resident (#3). Findings include, but not limited to: During an observation and interview, Resident 3 engaged their call light at 12:38 pm. A caregiver responded to the call light at 1:00 pm (22 minutes) and assisted Resident 3 to the bathroom. During the interview on 06/14/23, Resident 3 stated s/he regularly has to wait a very long time for help from a caregiver, sometimes up to 45 minutes. Resident 3 thinks his/her bladder infections are caused by having to hold urine for so long while waiting to get assistance. S/he further stated, it is really stressful when s/he has to wait, and weekends are the worst time for staffing related to the the facility being short-staffed.  S/he reported sometimes they have to call the front desk to get someone to help. During interviews on 06/14/23, Staff 4 (caregiver), Staff 5 (LPN) and Staff 6 (Medication Technician) stated call lights should be responded to within 15 minutes. Staff 4, Staff 5 and Staff 6 all stated "there is not enough staff to meet resident needs sometimes", especially if there are multiple residents using their call lights at the same time. Resident 3's call light logs for 05/15/23 through 06/14/23 revealed 36 occasions when Resident 3 waited longer than 15 minutes for a response to his/her call light. Ten of those occasions were longer than 45 minutes. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 06/14/23. The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Verbal plan of correction: Staff 1 to review call light logs weekly and discuss in the health services meeting. S/he will review the ABST process with the home office to develop a consistent staffing process. The facility was currently undergoing a transition with the staffing coordinator who stepped down. The facility was actively recruiting for two staffing coordinators and direct care staff.

Based on interview and record review, during a site visit conducted on 06/14/23, it was confirmed that the facility failed to implement an Acuity-Based Staffing Tool (ABST). Findings include, but not limited to: During interviews on 06/14/23, Staff 1 (Executive Director), Staff 2 (Director of Nursing), and Staff 3 (Quality Care Coordinator) stated their care-planning platform, Service-Minder tool had their ABST built-in. The document used was called "Summary by Provider". They entered the residents data into the tool to generate how many hours of care was needed per day to figure out the facilities staffing plan. The process was completed once a month. If a resident had a service plan change, it would be reflected immediately in the summary by the provider, but not on the ABST. If residents had changes of conditions that required service plans updates and increased level of care, they stated they would discuss that in the morning meeting, and Staff 3 would update the schedule for the week. A review of the May 2023 ABST documents provided lacked residents' names. The Compliance Specialist requested  the ABST for June 2023 or any current ABST documentation. Staff 1 was unable to provide documentation of the June 2023 ABST, as it had not yet been completed, and would not be until July 2023. The facility was unable to provide documentation of their ABST review process for new move-ins, updates with service planning or changes of conditions. There was no documented evidence the facility changed their staffing plan to reflect resident care needs. The finding were reviewed with and acknowledged by Staff 1 on 06/14/23. The facility failed to fully implement an ABST. Verbal plan of correction: Staff 1 will contact the home office for regarding the facilities ABST and staffing. Until that time, they will review their "summary by provider" report and staffing schedule in daily health services meeting and document the review for new move-ins, changes in service planning/care needs, and changes of conditions, and implications for staffing needs.

The findings of the on-site investigation, conducted 06/14/22 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.

Based on observation and interview, it was determined the facility failed to ensure food preparation and service, storage, and dish machine temperatures were in accordance with the Food Sanitation Rules OAR 333-150-0000.  Findings include, but are not limited to: On 9/20/2022, between 10:35 am to 12:10 pm, the following areas of concerns were observed in the kitchen: *The powdered sugar container had a paper cup in it and a container of brown rice was open without anything covering it. * Five containers of cold cereal were stored with paper cups in them. In the same area a container of brown sugar had a scoop in it and was uncovered, a container of raisins was also uncovered. The area was a high traffic area for kitchen staff. * At 10:45 am and 12:00 noon, the reach in refrigerator within the kitchen, which had access to the dining room staff had a temperature of 52.5 degrees F and 56.5 degrees F respectively. During observations the refrigerator indicated it was in a defrost cycle. Kitchen staff had documented the "closing check" temperatures on the temperature log 9/19, 9/18 and 9/17/2022 as 64 degrees F, 61 degrees F and 62.5 degrees F. Morning temperatures were less than 41 degrees F. Staff 1 (Executive Director), Staff 2 (Dining Room Supervisor) and Staff 3 (Kitchen Supervisor) were advised of findings and will address with maintenance staff immediately. Staff 2 indicated the rolling carts in the refrigerator were moved into the walk in refrigerator every night. * Pork loin was observed in a container of cold water, the faucet was not running cold water at the time of the observation. Staff 3 stated the water had been running previously. * Breakfast food items were observed in the steam table during the inspection, per Staff 3 breakfast was served from 8:00 am to 12:00 noon daily. Sausage patties were observed on the counter in a steam pan, food prep staff stated patties and the food in steam table would be disposed of and not served again. Diced chicken in a container  being prepped for a lunch salad was not being held in an ice bath to keep chilled. * The dishwashing machine had a data plate indicating both high and low temperatures for its usage. Observed temperatures included wash at 147 degrees F and rinse at 168 degrees F. Staff 1, 2 and 3 were advised of the situation. * Dishwashing staff was observed to handle clean dishes without handwashing or rinsing after handling soiled dishes. *Walls by and above the three compartment sink in the dishwashing room had food drips/splatter. * A fan operating  above the clean dish area had significant accumulation of dust. The top shelf of a rack in the dish room had significant accumulation of dust. * The floor under the stove and range top had buildup of black matter/grease. The above areas of concern were discussed with Staff 1, Staff 2 and Staff 3. The findings were acknowledged.

1.  What actions have been taken to correct the violation:        a.  All paper cups have been removed from storage containers.      b.  All containers now have secure fitted lids      c.  Bulk cereals will be discontinued and replaced with single service items.        d.  Commercial Refrigeration came and repaired the reach in fridge and new temp logs show that the fridge is keepimg temps.  The fan motor was repaired/replaced.      e.  All meat that is being thawed in the sink will have running water on it.      f.  All food being held on the line will be held using time and temperature method (i.e. sausage would be temped as required and diced chicked would be held in an ice bath).      g.  The dish machine is hooked up and working as a chemcial sanitizing machine via Ecolab.      h.  All staff will handle clean dishes utilizing appropriate hand sanitizing techniques.      i.  Walls have been cleaned above the 3 compartment sink.      j.  Fan has been cleaned.      k.  The floor has been cleaned under the stove and range and a professional cleaner has been hired to clean the floors and walls on back line. 2.  How will system be corrected so that violation does not occur again?     a.  All staff will be educated on safe food handling/cross contamination.     b.  Dish washers have been educated on proper hand washing/sanitizing while handling clean dishes.     c.  We have insured we have the correct lids for the correct containers for appropriate storage of food.     d.  All staff have been educated on the cleaning schedule and requirements.     e.  Reach in refrigerator is monitored daily, if there is a discrepancy with the temps Maintenance is notified. 3.  How often will the areas needing correction be monitored? a.  Administrator, Culinary Director or designee with complete a weekly audit of the kitchen to inspect for safe food handling, appropriate hand washing and cleanliness of the kitchen.  A daily temp log is kept on the fridges/freezers.

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

4.  Who will be responsible to insure the corrections are completed/monitored?     a.  The Administrator, Culinary Director or designee will complete training and audits to insure compliance with plan of correction. Z 142 1.  What actions have been taken to correct the violation:        a.  All paper cups have been removed from storage containers.      b.  All containers now have secure fitted lids      c.  Bulk cereals will be discontinued and replaced with single service items.        d.  Commercial Refrigeration came and repaired the reach in fridge and new temp logs show that the fridge is keepimg temps.  The fan motor was repaired/replaced.      e.  All meat that is being thawed in the sink will have running water on it.      f.  All food being held on the line will be held using time and temperature method (i.e. sausage would be temped as required and diced chicked would be held in an ice bath).      g.  The dish machine is hooked up and working as a chemcial sanitizing machine via Ecolab.      h.  All staff will handle clean dishes utilizing appropriate hand sanitizing techniques.      i.  Walls have been cleaned above the 3 compartment sink.      j.  Fan has been cleaned.      k.  The floor has been cleaned under the stove and range and a professional cleaner has been hired to clean the floors and walls on back line. 2.  How will system be corrected so that violation does not occur again?     a.  All staff will be educated on safe food handling/cross contamination.     b.  Dish washers have been educated on proper hand washing/sanitizing while handling clean dishes.     c.  We have insured we have the correct lids for the correct containers for appropriate storage of food.     d.  All staff have been educated on the cleaning schedule and requirements.     e.  Reach in refrigerator is monitored daily, if there is a discrepancy with the temps Maintenance is notified. 3.  How often will the areas needing correction be monitored? a.  Administrator, Culinary Director or designee with complete a weekly audit of the kitchen to inspect for safe food handling, appropriate hand washing and cleanliness of the kitchen.  A daily temp log is kept on the fridges/freezers. 4.  Who will be responsible to insure the corrections are completed/monitored?     a.  The Administrator, Culinary Director or designee will complete training and audits to insure compliance with plan of correction.

The findings of the kitchen inspection conducted on 9/20/2022, are documented in the this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities fro Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection survey of 09/20/22, conducted 11/16/22 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.

Based on interview and record review it was confirmed that the facility failed to have policies and procedures in place to assure the prevention and appropriate response to any incident. Findings include but not limited to: During an unannounced site visit on 6/23/22, Staff #3 (S3) indicated that Resident #3 (R3) was left on the toilet for 30 minutes which caused her pain on 8/29/2021. Compliance Specialist (CS) requested and reviewed all incident reports dated 7/21/2021 through 6/12/2022 related to R3 and an incident report for the above incident was not included. The facility was unable to produce an incident report for this event and could not confirm that an investigation of this event had been completed and was not self-reported to Adult Protective Services (APS). These findings were reviewed with and acknowledged by Staff #1-#3 (S1-S3) Facility Plan of Correction: Review of Abuse reporting guide by Executive Director and Resident Care Coordinators. Facility will report any incidences involving medication errors, injuries of unknown origin to Adult Protective Services for them to rule out abuse/neglect in addition to conducting their own investigations in both RCF and endorsed memory care unit.