Miracle Heights at Happy Valley

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:

On 10/02/25 at 9:52 am, the facility main kitchen was observed.

1. The following areas needed cleaning:

* Juice machine - an accumulation of splatters;
* Industrial can opener - black matter;
* Ice machine vent - layers of dust, and the side of the ice machine had food debris and residue;
* Rack legs throughout the kitchen - black build-up;
* Side of plate holder - black matter;
* Handwashing sink area - black matter;
* The shelf above the two-compartment sink – food debris and black residue;
* A sink next to the two-compartment sink, the soap box, and towel dispenser were sticky to the touch and had dust and residue;
* Mixer - food debris and black residue; and
* The ceiling vent near the walk-in cooler - accumulated dust.

2. Improper food storage:

* Inside the prep cooler – multiple open items were not completely sealed, and food items did not have an open date;
* In the three-door freezer - an open package of meatballs was not dated; an open bag of hash browns was not completely covered or sealed and had no open date; and an open package of pepperoni had no open date;
* Two-door refrigerator – undated open container of canned food;
* In the dry food storage area - open brown sugar was not completely covered or sealed and had no open date; an open container of buttermilk pancake mix was not dated; open mashed potato starch was not completely sealed and had no open date; and in the bulk rice container the scoop was stored inside; and
* In the walk-in cooler – a partially melted bag of shrimp was stored next to cucumbers and carrots, and raw turkey was stored next to the sauces.

3. Other areas of concern include:

• Staff 3 (Assistance Cook) was observed with a ponytail that was not restrained;
• Between 10:50 am and 10:55 am, Staff 2 (Cook) handled spam with gloved hands while cutting it. She failed to change gloves between multiple tasks;
• No sanitizing solution was available for cleaning surfaces; and
• Staff 2 failed to check temperature of food after cooking.

The areas of concern were observed and discussed with Staff 1 (ED) on 10/02/25 at 12:00 pm. The findings were acknowledged.

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 ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 11/05/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas:

* Refrigerator next to steam table – drips/spills on exterior doors;
* Steam table – drips/spills on front around control knobs;
* Plate warmer – drips/spills on side next to steam table;
* Ice maker – black matter on interior bracket that drops ice cubes;
* Flooring between steam table and plate warmer and behind cooking equipment – buildup of grease/debris/black/brown matter; and
*Wall behind spray hose in dishwashing area – caulking with black matter.

The areas of concern were observed and discussed with Staff 1 (Cook) and discussed with Staff 2 (Owner) and Staff 3 (Resident Care Coordinator) on 11/05/24. The findings were acknowledged.

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 kitchen inspection, conducted 09/28/23, 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 revisit to the kitchen inspection of 09/28/23, conducted 11/06/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 09/28/23 at 11:05 am, the facility kitchen was observed and the following were identified: * No pasteurized eggs were available and per interview with Staff 1 (Cook), soft cooked eggs were prepared and served to residents. * No testing strips were available to test bleach solution used for sanitation purposes. The findings were discussed with Staff 1 and Staff 2 (Executive Director) on 09/28/23. The findings were acknowledged.

The findings of the site visit conducted on 06/02/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, during a site visit on 06/02/23, it was confirmed the facility failed to provide proper notification to 1 of 1 sampled resident (#1) to move-out of the facility. Findings include, but are not limited to:A review of Resident 1's records revealed there was no documented evidence the facility issued an involuntary move-out notice to the resident. In a phone interview on 06/02/23, Witness 2 (Family Member) stated the facility had not provided any written notification regarding an involuntary move-out. S/he stated Staff 2 (Business Office/HR Manager) called him/her on 06/01/23 and said Resident 1 would be unable to return to the facility related to "the State would not allow them to legally take another two person transfer because they already have two."In an interview on 06/02/23, Staff 2 stated s/he told Witness 2 that Resident 1 was "no longer a good fit with the facility's current staffing standards." The facility failed to provide proper move-out notification to the resident.Those findings were reviewed with and acknowledged by Staff 1 (RN) on 06/02/23.Verbal Plan of Correction: The facilities RN stated they would accept the resident back with hospice and proper transfer equipment. Next time the facility staff would be sure to discuss goals of the resident care needs with family and hospital staff.

The findings of the initial survey conducted 08/30/22 through 09/01/22 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 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 first re-visit to the re-licensure survey of 09/01/22, conducted on 12/13/22, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure the kitchen staff were following safe food handling practices and food storage was in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: a. During observations of two cooks and the lunchtime meal preparation process on 08/30/22 and 08/31/22, the following issues were identified:* A cook failed to use a proper sanitation solution when wiping down food preparation surfaces; and* A cook did not disinfect the probe thermometer between testing different food items.b. During observations of the lunchtime meal service in the dining room on 08/30/22 and 08/31/22, the following issues were identified:* Direct care staff were not provided clean aprons prior to serving residents; and* Staff failed to consistently sanitize their hands or don gloves prior to serving residents and failed to sanitize or change gloves after touching potentially contaminated surfaces, including the residents themselves, residents' wheelchairs, pagers and the kitchen door.c. Observation of the facility dry storage area and walk-in refrigerator indicated multiple food items were not sealed, labeled and dated once the package was opened. Scoops were left in large bins where brown sugar and flour were stored.The need to ensure that the facility follows safe food handling and proper food storage practices in accordance with the Food Sanitation Rules OAR 333-150-0000 was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 5 (Business Office Manager) on 09/01/22 at 9:45 am. They acknowledged the findings.

Based on interview, it was determined the facility failed to choose and implement an Acuity-Based Staff Tool (ABST) by July 1, 2022 to determine appropriate staffing levels for the facility. Findings include, but are not limited to:On 08/31/22, Staff 1 (ED) was asked to provide evidence the facility had implemented an ABST to determine appropriate staffing levels for the facility. Staff 1 stated the facility had not implemented an ABST.The need to ensure the facility implemented an ABST was reviewed with Staff 1 and Staff 2 (RN) on 08/31/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 3 of 4 newly-hired staff (#s 9, 12 and 13) and infectious disease prevention training was completed for 2 of 2 veteran staff (#s 18 and 19). Findings include, but are not limited to: On 08/30/22 and 08/31/22 training records were reviewed with Staff 5 (Business Office Manager). The following deficiencies were identified: a. Staff 9 (Kitchen Aide) was hired on (07/15/22). Staff 9 had not completed pre-service training in the following areas prior to beginning her job responsibilities: *Resident rights and values of CBC care; *Abuse reporting requirements;*Infectious disease prevention training was not completed by July 1, 2022; *Fire safety and emergency procedures; and*Written job description.b. Staff 12 (MT/CG) was hired on 04/14/22. Staff 12 had not completed pre-service infectious disease prevention training prior to beginning her job responsibilities.c. Staff 13 (CG) was hired on 07/28/22. Staff 13 had not been provided a written job description prior to beginning her job responsibilities.d. Staff 18 (CG) was hired on 08/22/21 and Staff 19 (MT/CG) was hired on 08/27/21. They had not completed infectious disease prevention training by July 1, 2022.The need to ensure that all newly hired staff completed pre-service orientation training prior to beginning their job responsibilities, and veteran staff completed infectious disease prevention was discussed with Staff 1 (ED) and Staff 5 (Business Office Manager) on 08/31/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 11 and 13) completed First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:Review of the facility's training records on 08/30/22 and 08/31/22 revealed the following: * Staff 11 (CG) was hired 04/29/22 and Staff 13 (CG) was hired 07/28/22. There was no documented evidence those staff completed First Aid and abdominal thrust training within 30 days of hire.The need to ensure all newly hired staff completed First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 1 (ED) and Staff 5 (Business Office Manager) on 08/31/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 veteran direct care staff (#15) completed a minimum of 12 hours of in-service training annually, including 6 hours on dementia care. Findings include, but are not limited to:Review of the facility's training records on 08/30/22 and 08/31/22 revealed the following: *Staff 15 (MT/CG), hired on 06/23/21, did not have documented evidence of 6 hours of annual in-service training related to dementia care.The need to ensure all staff have a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including 6 hours on dementia care topics, was discussed with Staff 1 (ED) and Staff 5 (Business Office Manager) on 08/31/22. They acknowledged the findings.

Based on interview and records review, it was determined that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records from 01/2022 through 07/2022 were reviewed. The fire drill records did not consistently include documentation of the following required components:*Problems encountered, comments relating to residents who resisted or failed to participate in the drills. In an interview on 08/31/22, Staff 1 (ED) stated the facility evacuated residents as part of the fire drill process, however, it was not including documentation of problems encountered, comments relating to residents who resisted or failed to participate in the drills. Staff 1 stated that he met individually with those residents who did not participate in the drills, however, he did not document the content of those meetings.The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 1 on 08/31/22. Staff 1 acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in locked storage. Findings include, but are not limited to: On 08/30/22 at 9:45 am, the surveyor conducted a walk-through of the facility and was able to access two unlocked closets containing toxic chemicals. The closets were located near resident rooms and could be accessed by residents.During a follow-up on 08/31/22 at 10:20 am, the storage closets were still observed to be unlocked.The need to ensure chemicals and toxic materials were secured in locked storage was discussed with Staff 1 (ED). He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit. Findings include, but are not limited to: On 08/30/22, the surveyor measured water temperatures in four resident units. The hot water temperature ranged from 96.3 to 132.3 degrees Fahrenheit. Staff 5 (Business Office Manager) and Staff 21 (Owner) were present for testing of the water temperatures. On 09/01/22, Staff 21 informed the surveyor that the temperatures had been adjusted the previous evening. The surveyor retested the same units and found the temperatures to be within the range of 110.2 and 117.2 degrees Fahrenheit. The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 1 (ED) on 08/31/22. Staff 1 acknowledged the facility needed to implement a system for monitoring water temperatures.