Touchmark at Mount Bachelor Village

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 01/30/26 at 11:30am to 1:45pm, the facility kitchen was observed to need cleaning and repair in the following areas: Areas in need of cleaning and/or repair: *Several areas on floor throughout kitchen-cracks, unsealed cement, non-cleanable surface; *Wall behind dishwasher-black, deteriorated caulk, non-sealed surface; and *Ceiling in dish room- flaking, water / heat damaged; and *Ware washing Equipment for Hot Water Sanitation- below minimum temperature requirements. During an observation on 01/30/26 at approximately 12:30pm, Staff 3 (Sous Chef) demonstrated the dish machine did not meet temperature requirements. Staff 1 (PIC/Executive Chef) reported several days of temperature recordings below requirements. Surveyor observed the kitchen did not have a three compartment sink for manual dishwashing. Staff planned to utilize the dish machine in the adjacent independent kitchen while repair was made. Surveyor observed the dish washer in the independent kitchen was meeting hot water temperature requirements. The areas of concern were observed and/or discussed with Staff 1 (PIC/Executive Chef), Staff 2 (Admin/Health Services Director) and Staff 3 (Sous Chef). Staff acknowledged the findings at approximately 1:45pm on 01/30/26.

Our Building Services will be repairing and resealing the areas identified. Grind down porous areas, paint and reseal to achieve a non-porous, cleanable and within regulations flooring. Caulking has been ordered and once it has arrived the old caulking will be removed and then will be resealed by our Building Services team. Panels have been ordered to replace the damaged ones and once they have arrived the damaged ones will be replaced with the new ones by the Building Services team. Repairman has come in and reconnected the water lines to the heat booster and the machine has been consistently hitting the required tempuratures above 180 degrees F. PIC is providing a Temp Log to be able to ensure daily compliance with this regulation. And three large containers that will be dedicated to provide a three-compartment sink setup as needed have been ordered. To ensure that the recent violations do not reoccur, the Building Services Director and the PIC for the kitchen will review kitchen environment on a quarterly basis.

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).

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.

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 C240.

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.

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records from 12/2023 through 06/2024 were reviewed with Staff 1 (Health Services Director) on 07/30/24, and the following was identified: a. The facility lacked documentation fire drills were being conducted on alternating months.   b. For fire drills which were completed between 12/2023 and 06/2024, the following required elements were not documented: * Escape route used; and * Evidence alternate routes were used during the fire drills. c. There was no documented evidence fire and life safety instruction for staff had been on alternate months. The need to provide fire and life safety instruction to staff and conduct unannounced fire drills on alternate months and document all required elements was discussed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings.

What actions will be taken to correct the rule violation? Alternating months of Fire and Life Safety training are Relias videos.  This has been reviewed and confirmed to be corrected for the remainder of the year and moving forward into 2025. The unannounced fired drills will continue to be scheduled and conducted every other month following calendar in the Fire and Life Safety Binder and calendar appointments to those who conduct and oversee these drills. . How will the system be corrected so this violation will not happen again? The Health Services Director/Administrator will confirm that the correct Fire and Life Safety videos are correctly populated when new hires are brought on for alternating months of active drills.   The correct form for fire drills will be used for all active fire drills on appropriate months and will have a detailed description of the route of evacuation and will ensure compliance of alternating those evacuation routes correctly documented.   How often will the area needing correction be evaluated? This will be done at time of hire, ensuring correct Relias training templates, and on alternating months of the active fire drills ensuring correct documentation. Who on your staff will be responsible to see that the corrections are completed/monitored? The Health Services Director/Administrator

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 C420.

** See previous POC for tag C420

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 caregiving staff (#s 6, 8, and 13) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (Health Services Director) on 07/30/24 and 07/31/24. There was no documented evidence Staff 6 (CG), hired 06/04/24, Staff 8 (MA), hired 06/12/24, and Staff 13 (CG), hired 03/11/24, had demonstrated competency all job duties including: * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings.

What actions will be taken to correct the rule violation? Checklist has been updated to cover all the required training competencies, including role of service plan, Relias videos covering providing assistance, changes associated with normal aging, Identifying, documentation and reporting changes of condition and Conditions that require assessment, treatment, observation and reporting have been confirmed to be correctly templated with state approved trainings.  Additionally, all team members have completed any missing training to come into compliance with the required training in the first 30 days.   How will the system be corrected so this violation will not happen again? Moving forward, no team members will be allowed to work without the Health Services Director/Administrator reviewing that all training and documentation of training is complete before working the floor solo. How often will the area needing correction be evaluated? Upon new hire and again within the 30 days of start date. Who on your staff will be responsible to see that the corrections are completed/monitored? The Health Services Director/Administrator.

The findings of the re-licensure survey, conducted 07/29/24 through 07/31/24, 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 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 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 revisit to the re-licensure survey of 07/31/24, conducted on 09/20/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, record review and interview, it was determined the facility failed to maintained the kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 07/21/22 revealed: * Splatters, spills, drips, and debris noted on: - Shelving below the tray line; - Stainless steel shelves; - Food bins; - Dishwashing area; - Warming drawers and oven interior in the Memory Care kitchenette; and - Interior of the cupboards and drawers in the Memory Care kitchenette. * Damaged laminate on the shelving below the tray line creating an un-cleanable surface. * Undated, uncovered, and unlabeled food items were noted in the walk in refrigerator. * At 11:00 am, three plates of breakfast food were in the microwave in the Memory Care kitchenette. * Numerous dented cans were noted in the dry storage closet. * Scoops were left lying in bins of food. * Staff were observed with hair unrestrained. * There was no evidence the operation of the high temperature dish sanitizer was being monitored. The dish machine was observed to operate multiple times and inconsistently registered the required temperatures for sanitation. The repair company was immediately contacted. * Dish racks were stored directly on the floor in the dishwashing room. * A residential dishwasher was being used in the Memory Care kitchenette. Staff 1 (Administrator) was informed of the need to utilize the commercial dish machine based on the facility census. Staff 3 (Sous Chef) and the surveyor toured the main kitchen. Staff 3 acknowledged the above findings. Staff 1 and the surveyor toured the Memory Care kitchenette. Staff 1 acknowledged the findings. The areas in need of cleaning and repair, food storage concerns, and the need for hair to be restrained were reviewed with Staff 1 and Staff 2 (Dining Room Manager). They acknowledged the findings.

*Splatters, spills, drips, and debris on shelving below the tray line,stainless steel shelves, food bins, dishwashing area, warmer drawers, oven interior in memory care kitchenette, interior cupboards and drawers in the memory care kitchenette cleaned. Dining services team is monitoring cleanliness with each use, and meal serve out-checking off daily. Dining room manager to audit task is completed daily, with weekly audits at minimum. Memory care resident care manager to audit weekly that NOC team has cleaned cupboards and oragnized snacks nightly. Heritage main kitchen and memory care kitchenette will be walked thru with CBC checklist twice monthly until 9.19.22 to ensure compliance. Memory Care oven will be checked for cleanliness at minimum once monthly, life enrichment to place work order for clean up as needed. *Damaged laminate on the shelving below tray line to be sealed with cover material, in order to be a cleanable surface. Building services director to have quote to replace surface by 9.19.22. *Undated, uncovered, and unlabeled food items in the walk in refrigerator to be labeled with every serve out by dining servers and team. The dining room manager will ensure daily completion, with at minimum once weekly audit. *Meals for residents eating later will be placed in to go boxes, dated and placed in refrigerator by dining servers with each meal as needed. Shakes and other items to be dated by dining servers. *Dented cans to be returned upon delivery. Dining services manager and Director to audit with every delivery. *Scoops no longer kept in dry bins of food as of walk thru 8.4.22. Twice monthly kitchen walk to be conducted thru 9.19.22. A *Dining services re-training on 8.4.22 regarding unrestrained hair and hair net use along with hair being restrained. Dining room manager and designee to observe daily for compliance. *High temperature dish sanitizer monitored with each use on checklist. Dining services manager to audit weekly for completion. *Dish racks no longer kept on the floor as of 8.4.22. Team to monitor with every use of dishwasher. Re-training to staff proved 8.4.22. *Residential dishwasher in memory care water disconnected, dishwasher no longer in use. Items will be removed frm dishwasher if used for activity. All memory care dishes will be cleaned with high temperature dish sanitizer only. Dining services director and dining room manager to monitor completion. All memory care staff re-trained by 8.4.22. The RCF administrator on file will continue to monitor the plan of correction with the dining room manager and dining services director at a minimum of every quarter, after 9.19.22 to prevent any deficiency recurrence. Continued monitoring plan of correction will be documented at increased frequency twice a month thru 9.19.22 by administrator on file and dining services team.

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.

See C240 plan of correction

The findings of the kitchen inspection, conducted 7/21/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 07/21/22, conducted 10/20/22, 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.