Manor Terrace Care Suites

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 OARs 333-150-0000. Findings include, but are not limited to:

Observations of the kitchen on 06/24/25 showed the following areas needed cleaning or repair:

a. An accumulation of food spills, splatters, dirt, dust, black matter, and/or grease was visible on, underneath, and/or behind the following throughout the ware washing area, server area, and kitchen:

* Stainless cabinets, drawers, and shelving;
* Sham warmers;
* Grill top and ovens;
* Plate warmer;
* Tilt skillet;
* Floors and walls;
* Floor drains;
* Ceiling vents;
* Ware washing machine;
* Caulking in the ware washing area;
* Walk-in refrigerator and freezer;
* Industrial can opener;
* Standing refrigerators; and
* Deli cooler.

b. The following areas were in need of repair:
* Multiple holes in walls were found in the kitchen and ware washing area; and
* Industrial mixer had chipped paint with bare metal and rust.

c. Ware washing racks were being stored on the floor.

On 06/24/25, the areas in need of correction in accordance with the Food Sanitation Rules OARs 333-150-0000 were reviewed with Staff 1 (Administrator) and Staff 2 (Dining Services Director). 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:

The findings of the re-licensure survey, conducted 05/01/23 through 05/03/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 05/03/23, conducted 07/26/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure residents with changes of condition were monitored until resolution for 2 of 3 sampled residents (#s 1 and 3) who experienced short-term changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 11/2021 with diagnoses including weakness and chronic pain.Resident 1's 01/30/23 through 05/02/23 progress notes, 02/22/23 through 03/22/23 physician visit notes, and 02/18/23 through 03/28/23 Temporary Service Plans (TSPs) were reviewed during the survey and showed the following:* 02/18/23: New medication Miralax for 14 days;* 02/21/23: New medication Norco every six hours as needed for pain;* 03/03/23: Received steroid injection in the right shoulder;* 03/14/23: Experienced abnormal walking; and* 03/28/23: Had gum pain.There was no documented evidence the resident's status was evaluated and the resident's condition was monitored to resolution.On 05/03/23, the above information was discussed with Staff 1 (Administrator). Staff acknowledged the findings.
2. Resident 3 was admitted to the facility in 04/2023 with diagnoses including dystonia and major depressive disorder.Resident 3's 04/04/23 through 05/1/23 progress notes, alert charting, and Temporary Service Plans (TSPs) were reviewed, and staff were interviewed. The following changes of condition were identified:* 04/04/23: Admission to the facility;* 04/11/23: Alert for rash discontinued;* 04/21/23: Diet change; and* 05/01/23: 30-minute checks discontinued.There was no documented evidence the changes were monitored through resolution, with progress noted at least weekly.The lack of documentation of monitoring through resolution was discussed with Staff 1 (Administrator) on 05/03/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 1 of 1 sampled resident (#1) whose MARs and Controlled Substance Disposition logs were compared for accuracy. Findings include, but are not limited to:Resident 1's 04/01/23 through 05/01/23 MAR and the Controlled Substance Disposition log were reviewed and revealed the following: * On five occasions; 04/01/23, 04/05/23, 04/06/23, 04/07/23, and 04/29/23, staff documented Tramadol 50 mg were administered on the Controlled Substance Disposition log. There was no documented evidence on the MAR the medication was administered to Resident 1 on those days.Inconsistencies between the MAR and Controlled Substance Disposition log were reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 05/03/23. They reviewed the documentation and acknowledged the discrepancies.

Based on observation, interview, and record review, it was determined the facility failed to ensure the use of a supportive device with restraining qualities was included in the resident's service plan and failed to instruct caregivers on the correct use of and precautions related to the supportive device for 1 of 2 sampled residents (#3). Findings include, but are not limited to:Resident 3 was admitted to the facility in 04/2023 with diagnoses including dystonia.The resident's 04/04/23 through 05/1/23 progress notes, alert charting, and Temporary Service Plans (TSPs) and his/her initial service plan were reviewed, observations were made, and staff were interviewed.Resident 3 was identified during the acuity interview on 05/01/23 as having side rails on his/her bed. On 05/02/23 at 10:20 am half side rails were observed on both sides of the resident's bed in the up position.During observation of a transfer with a Hoyer lift on 05/03/23, the resident was noted to use the side rails for repositioning.There was no documented evidence the use of side rails was communicated to staff on all shifts, instruction was provided to staff about the use of side rails, or the use of the supportive devices was added to the copy of the resident's service plan to which staff had access.The need to ensure the use of supportive devices with restraining qualities were added to resident's service plans with instructions for staff on the use of and precautions for supportive devices was discussed with Staff 1 (Administrator) on 05/03/23. She acknowledged the findings.