Coral Springs Residential Care

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main facility kitchen and memory care unit kitchenette on 09/11/25 from 10:00 am thru 2:00 pm and 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:

* Juice machine in dining room
* Wall behind trash can in dining room
* Removable hood vents
* Walk in cooler fan cage
* Industrial can opener housing
* Wall behind industrial mixer
* Wall behind dishwasher

b. The following areas needed repair:

* Wall behind trash can in dining room damaged/scored
* Bottom of side of cabinet in dining room
* Hand washing station near steam table without sustainable hot water for effective hand washing
* Left oven door not closing effectively for appropriate maintaining of cooking temperatures

c. Main kitchen and kitchenette areas did not have thin diameter thermometer probe as required for accurate temperature checks for thin foods.

d. Multiple cooking utensils and equipment with integrity concerns (dents, scrapes, heavy scoring, staining, melted spots, etc) and in need of replacement (pots, pans, spatulas, cutting boards, dome lids and bases, etc). Multiple white plates in memory care unit found with chips, cracks and scoring and in need of replacement.

e. Food contact surfaces of single services and/or cooking equipment/utensils were observed stored unprotected from potential contamination.

f. Multiple kitchen staff observed to reheat food items for residents in the microwave without demonstrating correct methods to ensure effective and even heating (i.e. stirring food item and allowing to sit/stand prior to checking temperature).

g. Multiple dished plates of breakfast items were observed in the memory care kitchenette at 12:24 pm when food was delivered to memory care unit for lunch service. Upon investigation with staff, facility practice is to plate a meal and cover and store on the counter for any residents not in the dining room at the time of service in case they wish to eat at a later time. The main kitchen staff then removes/discards the meals at the next meal service. Meal items for breakfast trays temperatures were checked and found at 72 degrees Fahrenheit greater than 4 hrs post meal service. Staff were unaware of the appropriate cooling time/temperature requirements and the need to discard any cooling food after 2 hrs if not at 70 degrees or below. Staff was not aware food should not be allowed to cool on the countertop for extended time frames.

h. A trash can was observed stored inside the dry storage/pantry area which is prohibited. Staff 2 was not aware trash receptacles could not be stored in food storage areas.

i. Staff serving resident meals in memory care kitchenette was observed to not change gloves appropriately after potentially contaminating them during meal service when switching tasks, touching handles, and then resuming plating of food items.

j. Cold food items (coleslaw and watermelon) were not transported on ice from main kitchen and were not held on ice during service and were noted to be at 49 degrees Fahrenheit prior to service. Cold food items should be at 41 degrees or below when served from tray line to maintain safety and palatable cold food temperatures.

Staff 2 toured kitchen areas with surveyors and acknowledged the identified areas in need of correction.

At approximately 1:45 pm, surveyors reviewed areas with Staff 1 (Administrator), Staff 3 (Memory Care Director) and Staff 4 (Wellness Nurse) who acknowledged the identified concerns.

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, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main facility kitchen on 09/11/25 from 10:00 am thru 2:00 pm and 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:

* Juice machine in dining room
* Wall behind trash can in dining room
* Removable hood vents
* Walk in cooler fan cage
* Industrial can opener housing
* Wall behind industrial mixer
* Wall behind dishwasher

b. The following areas needed repair:

* Wall behind trash can in dining room damaged/scored
* Bottom of side of cabinet in dining room
* Hand washing station near steam table without sustainable hot water for effective hand washing
* Left oven door not closing effectively for appropriate maintaining of cooking temperatures

c. Facility did not have thin diameter thermometer probe as required for thin foods.

d. Multiple cooking utensils and equipment with integrity concerns (dents, scrapes, heavy scoring, staining, melted spots, etc) and in need of replacement (pots, pans, spatulas, cutting boards, dome lids and bases, etc).

e. Food contact surfaces of single services and/or cooking equipment/utensils were observed stored unprotected from potential contamination.

f. Multiple kitchen staff observed to reheat food items for residents in the microwave without demonstrating correct methods to ensure effective and even heating (i.e. stirring food item and allowing to sit/stand prior to checking temperature).

g. Family member was observed to serve resident beverages from original containers that were used to serve other residents. This included observations of touching lids and handles without observed hand hygiene performed. This practice puts other residents at risk for potential infection control/cross contamination concerns. Staff 2 (Lead Cook/Person In Charge) also observed this practice and indicated they were uncomfortable of restricting the family member from engaging in that practice.

h. A trash can was observed stored inside the dry storage/pantry area which is prohibited. Staff 2 was not aware trash receptacles could not be stored in food storage areas.

Staff 2 toured kitchen areas with surveyors and acknowledged the identified areas in need of correction.

At approximately 1:30 pm, surveyors reviewed areas with Staff 1 (Administrator) who acknowledged the identified concerns.

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, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main facility kitchen and memory care unit kitchenette on 09/11/25 from 10:00 am thru 2:00 pm and 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:

* Juice machine in dining room
* Wall behind trash can in dining room
* Removable hood vents
* Walk in cooler fan cage
* Industrial can opener housing
* Wall behind industrial mixer
* Wall behind dishwasher

b. The following areas needed repair:

* Wall behind trash can in dining room damaged/scored
* Bottom of side of cabinet in dining room
* Hand washing station near steam table without sustainable hot water for effective hand washing
* Left oven door not closing effectively for appropriate maintaining of cooking temperatures

c. Main kitchen and kitchenette areas did not have thin diameter thermometer probe as required for accurate temperature checks for thin foods.

d. Multiple cooking utensils and equipment with integrity concerns (dents, scrapes, heavy scoring, staining, melted spots, etc) and in need of replacement (pots, pans, spatulas, cutting boards, dome lids and bases, etc). Multiple white plates in memory care unit found with chips, cracks and scoring and in need of replacement.

e. Food contact surfaces of single services and/or cooking equipment/utensils were observed stored unprotected from potential contamination.

f. Multiple kitchen staff observed to reheat food items for residents in the microwave without demonstrating correct methods to ensure effective and even heating (i.e. stirring food item and allowing to sit/stand prior to checking temperature).

g. Multiple dished plates of breakfast items were observed in the memory care kitchenette at 12:24 pm when food was delivered to memory care unit for lunch service. Upon investigation with staff, facility practice is to plate a meal and cover and store on the counter for any residents not in the dining room at the time of service in case they wish to eat at a later time. The main kitchen staff then removes/discards the meals at the next meal service. Meal items for breakfast trays temperatures were checked and found at 72 degrees Fahrenheit greater than 4 hrs post meal service. Staff were unaware of the appropriate cooling time/temperature requirements and the need to discard any cooling food after 2 hrs if not at 70 degrees or below. Staff was not aware food should not be allowed to cool on the countertop for extended time frames.

h. A trash can was observed stored inside the dry storage/pantry area which is prohibited. Staff 2 was not aware trash receptacles could not be stored in food storage areas.

i. Staff serving resident meals in memory care kitchenette was observed to not change gloves appropriately after potentially contaminating them during meal service when switching tasks, touching handles, and then resuming plating of food items.

j. Cold food items (coleslaw and watermelon) were not transported on ice from main kitchen and were not held on ice during service and were noted to be at 49 degrees Fahrenheit prior to service. Cold food items should be at 41 degrees or below when served from tray line to maintain safety and palatable cold food temperatures.

Staff 2 toured kitchen areas with surveyors and acknowledged the identified areas in need of correction.

At approximately 1:45 pm, surveyors reviewed areas with Staff 1 (Administrator), Staff 3 (Memory Care Director) and Staff 4 (Wellness Nurse) who acknowledged the identified concerns.

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, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main facility kitchen on 09/11/25 from 10:00 am thru 2:00 pm and 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:

* Juice machine in dining room
* Wall behind trash can in dining room
* Removable hood vents
* Walk in cooler fan cage
* Industrial can opener housing
* Wall behind industrial mixer
* Wall behind dishwasher

b. The following areas needed repair:

* Wall behind trash can in dining room damaged/scored
* Bottom of side of cabinet in dining room
* Hand washing station near steam table without sustainable hot water for effective hand washing
* Left oven door not closing effectively for appropriate maintaining of cooking temperatures

c. Facility did not have thin diameter thermometer probe as required for thin foods.

d. Multiple cooking utensils and equipment with integrity concerns (dents, scrapes, heavy scoring, staining, melted spots, etc) and in need of replacement (pots, pans, spatulas, cutting boards, dome lids and bases, etc).

e. Food contact surfaces of single services and/or cooking equipment/utensils were observed stored unprotected from potential contamination.

f. Multiple kitchen staff observed to reheat food items for residents in the microwave without demonstrating correct methods to ensure effective and even heating (i.e. stirring food item and allowing to sit/stand prior to checking temperature).

g. Family member was observed to serve resident beverages from original containers that were used to serve other residents. This included observations of touching lids and handles without observed hand hygiene performed. This practice puts other residents at risk for potential infection control/cross contamination concerns. Staff 2 (Lead Cook/Person In Charge) also observed this practice and indicated they were uncomfortable of restricting the family member from engaging in that practice.

h. A trash can was observed stored inside the dry storage/pantry area which is prohibited. Staff 2 was not aware trash receptacles could not be stored in food storage areas.

Staff 2 toured kitchen areas with surveyors and acknowledged the identified areas in need of correction.

At approximately 1:30 pm, surveyors reviewed areas with Staff 1 (Administrator) who acknowledged the identified concerns.

Z 142: 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.

The findings of the re-licensure survey, conducted 12/13/22 through 12/15/22 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 Home and Community Based Services Regulations OARs 411 Division 004.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 re-visit to the re-licensure survey of 12/15/22, conducted on 03/02/23, 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 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 second revisit to the re-licensure survey of 12/15/22 conducted 04/05/23 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 observation, interview and record review, it was determined the facility failed to ensure service plans were consistently followed by staff for 1 of 4 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in November 2022 with diagnoses including Parkinson's disease. Observations of the resident, interviews with staff and review of the service plan dated 11/17/22, showed the resident was dependent on staff for care, had frequent falls and a pressure wound on his/her left heel. The service plan was not consistently followed by staff in the following areas: * Floating heels;* Foam booties for both feet;* Fluids within reach; and* Bed in the lowest position;The need to ensure resident service plans were consistently followed was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 4 (RCC), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#3) who experienced significant changes of condition related to pressure ulcers. Findings include, but are not limited to:Resident 3 was admitted to the facility in November 2022 with diagnoses including Parkinson's disease. Review of progress notes, wound assessments, temporary service plans and hospice notes dated 12/01/22 through 12/13/22 and the service plan dated 11/17/22 showed the following:* A progress note dated 11/23/22 indicated Staff 3 (LPN) was notified of a blister to resident's left heel.* A wound assessment dated 12/02/22 indicated an intact blister, 4.0 cm in diameter was present on the left heel. * A wound assessment dated 12/09/22 indicated the wound had black eschar (dead tissue), no drainage or change in size. There was no assessment completed by the RN when the wound was discovered on 11/23/22. In interview on 12/14/22, Staff 5 (RN) indicated the area on the resident's heel was not present on admission. The blister started as a stage 2 pressure area. Staff 5 stated the heel wound transitioned to an unstageable pressure area, but was making improvements. Staff 5 stated she had not completed a significant change of condition assessment related to the resident's pressure area. The facility failed to ensure an RN assessment was completed for the pressure wound which documented findings, resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 5. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 2 of 2 sampled residents (#s 2 and 3) who were prescribed PRN medications to address behaviors. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in November 2022 with diagnoses including Parkinson's disease. Review of the resident's 11/17/22 through 12/13/22 MARs and progress notes and 12/07/22 physician orders showed the following:* Lorazepam 0.5 mg (anti-anxiety medication), one tablet every two hours PRN for anxiety or difficulty breathing. The Lorazepam was administered nine times between 12/01/22 and 12/13/22. * Haloperidol lactate 2 mg/ml, take 1.0 ml every two hours PRN for agitation. The Haloperidol was not administered between 12/01/22 and 12/12. The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety, distress or agitation. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medication. The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 4 (RCC), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. The staff acknowledged the findings.On 12/15/22, Staff 1 indicated Hospice was now discontinuing the resident's Haloperidol. 2. Resident 3 was admitted to the facility in December 2022 with diagnoses including multiple myeloma. Review of the resident's 12/07/22 through 12/13/22 MARs and progress notes and 12/10/22 physician orders showed the following:* Lorazepam 0.5 mg (anti-anxiety medication), one tablet every two hours PRN for anxiety, agitation and/or nausea. The Lorazepam was not administered between 12/01/22 and 12/13/22. The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety or agitation. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medication. The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 4 (RCC), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in December 2022 with diagnoses including multiple myeloma and chronic pain.Observations of the resident, interviews with staff and review of the service plan dated 12/07/22, showed the resident had two half side rails at the head of his/her bed. The resident required one staff assistance for ADL care and was a fall risk due to self transfers. Review of the resident's record showed no RN, PT or OT assessment was completed for the use of the siderails. The need to ensure resident devices with restraining qualities, were assessed by the RN, a PT or OT was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 4 (RCC), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure an assessment was completed by the facility RN, PT, or OT prior to the use of a supportive device with restraining qualities and/or was evaluated quarterly for 3 of 3 sampled residents (#s 1, 3 and 4) . Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 04/2020 with diagnoses including stroke and post polio subdural hematoma.The resident was identified to have a lap buddy during the acuity interview. The device was observed on the resident's wheel chair multiple times during survey. Staff reported the lap buddy prevented the resident from falling out of the chair. Resident 1 was observed in the dining room on 12/13/22 at 12:15 pm, sitting in the wheel chair with a lap buddy in place. The resident was leaning to the left and forward in the wheel chair. Two care staff repositioned him/her in the wheel chair on three occasions before the lunch meal was served. There was no documented evidence an assessment had been completed by an RN, PT, or OT prior to use of the lap buddy and there were no quarterly evaluations documented. The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and evaluated quarterly was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. They acknowledged the findings. No further information was provided.2. Resident 4 was admitted to the facility in 09/2021 with diagnoses including chronic back pain, congestive heart failure and chronic kidney disease. The resident was observed on 12/13/22 while up in the wheel chair to have a belt wrapped around the bottom of the wheel chair foot rest and buckled over the top of his/her feet. Staff 3 (LPN) stated that the belt kept the resident's feet from slipping off the footrest and the resident wanted the belt or a Velcro strap used. There was an RN assessment for use dated 09/15/21, although there were no quarterly evaluations for use of the device.The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and evaluated quarterly was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 5 (RN) and Staff 19 (Director of Nursing Services) on 12/14/22. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:During a review of the facilities ABST on 12/14/22, it was determined the tool failed to include all of the 22 required ADL components to include: *Personal hygiene;*Grooming;*Dressing/undressing;*Bathing;*Repositioning in bed or chair;*Ambulation, escorting to and from meals or activities;*If multiple staff are required to assist with transferring and completing tasks in previous question, how much additional time is needed; *Medication administration;*Providing treatments;*Assisting with leisure activities;*Monitoring physical condition or symptoms;*Assisting with communication, assistive devices for hearing, vision or speech;*Responding to call lights;*Completing resident specific housekeeping or laundry services performed by care staff;*Additional care service, such as smoking assistance or pet care; and*Ambulation assist to and from meals.The ABST tool was reviewed and discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 19 (Director of Nursing Services) on 12/14/22 at 10:20 am. Staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to:During a review of the facilities ABST on 03/02/23, it was determined the tool failed to include all of the 22 required ADL components to include: * Personal hygiene;* Grooming; and* Providing treatments (e.g., skin care, wound care, antibiotic treatment).The ABST tool was reviewed and discussed with Staff 1 (Administrator) and Staff 2 (ED) on 03/02/23 during the survey. Staff acknowledged the findings.

Based on interview and record review, 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 C 361.