Marquis Eugene Memory Care

Based on observation, interview, and record review, conducted during a site visit on 04/17/25, the facility's failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: Six direct care staff were observed to be working during day shift on 04/17/25.A review of the ABST indicated the following:· Day shift: 6.41 staff required;· Swing shift: 5.67 staff required; and· Night shift: 2.05 staff required.A review of the posted staffing plan and staffing schedules for 04/11/25 through 04/17/25 indicated the following:· Day shift: six staff required;· Swing shift: six staff required;· Night shift: three staff required;· The posted staffing plan did not exceed the ABST care time for day shift; and· The facility was not staffed per the ABST for two of 21 shifts.In an interview, Staff 1 (Executive Director) stated s/he had been taking an average of the daily hours on the ABST instead of using the highest care need times.Findings were reviewed with and acknowledged by Staff 1 on 04/17/25.The facility failed to use the results of an ABST to develop and update the facility's posted staffing plan; and the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

Based on observation, interview, and record review, conducted during a site visit on 04/17/25, the facility's failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: Six direct care staff were observed to be working during day shift on 04/17/25.A review of the ABST indicated the following:· Day shift: 6.41 staff required;· Swing shift: 5.67 staff required; and· Night shift: 2.05 staff required.A review of the posted staffing plan and staffing schedules for 04/11/25 through 04/17/25 indicated the following:· Day shift: six staff required;· Swing shift: six staff required;· Night shift: three staff required;· The posted staffing plan did not exceed the ABST care time for day shift; and· The facility was not staffed per the ABST for two of 21 shifts.In an interview, Staff 1 (Executive Director) stated s/he had been taking an average of the daily hours on the ABST instead of using the highest care need times.Findings were reviewed with and acknowledged by Staff 1 on 04/17/25.The facility failed to use the results of an ABST to develop and update the facility's posted staffing plan; and the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

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 kitchenette on 02/21/25 from 10:30 am thru 1:30 pm revealed the following deficient practices.

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black and/or white matter and grease was visible on or underneath the following:

* Pipes, drain, walls and flooring behind/underneath of the dish machine;
* Floors/walls/edges between/under tables/workspaces;
* Walls behind and across ice machine;
* Floors under, behind, and beside ice machine;
* Multiple kitchen drains;
* Ceiling vents and light fixtures;
* Walls behind prep spaces/cooking areas or trashcans;
* Sides of Fryer, Stove, and ovens;
* Floors between, under and behind large equipment;
* Floors in walk in cooler and freezer;
* Shelving in walk in cooler, freezer;
* Portable baking and storage racks:
* Open stainless steal shelving;
* Open shelving above steam line;
* Shelving under gas grill;
* Large can opener and housing;
* Interior of reach in deli cooler;
* Rack shelving in dry good storage;
* Large can good rack in dry storage;
* Utility carts;
* Wall behind stove/grill;
* Interior of unit full sized reach in refrigerator and freezer;
* Interior of the unit small snack refrigerator;
* Unit Ice and water dispensers; and
* Interior of cupboards and drawers in unit kitchenette;

b. The following areas needed repair:

* Area of flooring just inside kitchen entry door with a gap in one of the seams with an accumulation of dirt/debris.

c. Kitchen staff member observed to handle dirty dishes, touch the garbage disposal and sprayer nozzle with gloves on and then handle clean dishes with the same gloves. Same staff was observed to handle trash can lid and then rinse his gloves in soapy water and dry with a paper towel then handle clean dishes. Staff 2 was informed and indicated they confirmed witnessing the same practice. Staff 2 then went over to kitchen staff and provided education on the need for a clear hand hygiene step between dirty and clean tasks. Surveyor discussed with staff 2 that disposable gloves cannot be “washed” that staff need to remove gloves and wash hands then don clean gloves if/when gloves are used.

d. Dish machine wash was observed to not reach 150 degrees during the wash cycle after 3 loads observed where the temps ranged 144-146 degrees Fahrenheit. Surveyor asked kitchen employee what the sanitizing factor was (ie was the machine a low temp chemical or a high temp machine for its sanitization agent). Kitchen employee washing the dishes was not able to state what the sanitizing factor was. Staff 2 indicated that the dish machine wash temperature at times does not reach 150 if multiple loads have occurred and when that happens staff are to allow the machine to “rest” so that it can recalibrate. Staff 2 indicated staff doing dishes are to watch out for the need to let the machine rest. Staff 2 also indicated if the machine did not reach its final required 180 for sanitizing the machine would extend its cycle until it could reach the required sanitizing temp. They stated when that happens it is unmistakable as the cycle “lasts forever” and you know you need to run it again. Staff 2 validated there wasn’t a alarm or other indicator other than looking at the temperature of the wash cycle to know if the 150 degrees was reached per manufactures and food code guidelines. After allowing the dish machine to sit for approximately five minutes, staff continued washing dishes and the wash temperature reached 150 and the rinse reached 180 degrees as required. Originally the staff member observed had not recognized the machine was not operating as required and needed the “rest” period to function properly. It is unclear how many loads of dishes were completed where the machine was not functioning correctly.

e. Multiple individual yogurts were found stored in the full sized reach in refrigerator on the memory care unit that were four days past the manufactures use by dates of 02/17/25.

At 12:45 pm, above findings were reviewed with Staff 1 (Executive Director) and the acknowledged the above areas in need of correction. At 1:15pm staff 2 (Dietary manager) was interviewed and they acknowledged the identified areas. At 1:30 pm, Staff 3 (Memory Care Administrator) was informed of the areas in need of correction and they acknowledged the areas.

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 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.

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.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 06/22/23, 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 first revisit to the kitchen inspection of 06/22/23, conducted 08/24/23, 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, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observation of the memory care kitchenette on 6/22/23 at 11:00 am through 2:00 pm revealed the following deficiencies: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:* Flooring with spills, and loose food debris and sticky in places;* Drain under sink with accumulation of food debris;* Ice and water dispenser;* Interior of reach in refrigerator under the counter;* Interior of the freezer; and * Interior of drawers and cupboards.b. Scoops were observed stored in coffee and brown sugar containers;c. Containers of dished up sherbet were stored in the freezer uncovered and open to possible contamination. Coffee filters were stored open to potential contamination.d. Kitchenette area did not have thermometers available to check temperatures of food items. Staff members present stated they do not check temperatures of food items. e. Clean rags were stored under the sink on top of chemicals and close to dirty drain posing potential contamination during storage.f. Side salad and vegetables were stored in reach in fridge covered but without date or label. These were items that residents did not eat and were reserved for them for a later time but were not dated or labeled for which resident as required. The surveyor reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas. At 2:00 pm the surveyor reviewed the areas in need of cleaning and inappropriate storage practices with Staff 1 (Administrator) and Staff 3 (Campus Executive Director) They acknowledged the areas.

Based on observation, record review 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.

The findings of the re-licensure survey, conducted 05/02/22 through 05/04/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.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 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 re-visit to the initial survey of 05/04/22, conducted 07/13/22, 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 for Home and Community Based Services Regulations. The facility was found to be in substantial compliance with the regulations.

Based on interview and record review, it was determined the facility failed to ensure that actions and interventions were determined, documented, communicated to staff on all shifts and the resident monitored based on his or her evaluated needs for 1 of 2 sampled residents (#2) who experienced short-term changes of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in February 2022 with diagnoses including dementia. The resident's 01/29/22 service plan, 02/01/22 through 05/03/22 progress notes and current physician orders were reviewed. The facility failed to determine and document actions and interventions needed for the resident, communicate interventions to staff and monitor short term changes in condition at least weekly to resolution in the following areas:* Emergency room visits;* Tremors; and* Medication Changes.The need to ensure that actions and interventions were determined, documented and communicated to staff and the resident's condition was monitored to resolution was discussed with Staff 17 (MC Administrator) and Staff 11 (Health Services Director/RN) on 05/04/22. They 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 residents (#1) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 1 was admitted to the facility in April 2022 with diagnoses including dementia, abdominal pain and anxiety. Resident 1's signed physician orders, dated 04/07/22 included the following orders:* Lorazepam 0.5 mg tablet, give 0.5 tab (0.25 mg) by mouth three times a day PRN for anxiety/agitation unmanageable with non-drug interventions. If PRN not effective within one hour may administer second 0.5 tab (0.25 mg). Resident 1's Controlled Substance Disposition logs and MARS, for 04/07/22-05/02/22 showed the following:* On 04/09/22, 04/16/22, 04/21/22 and 04/30/22 doses of Lorazepam were recorded on the disposition log but not on the MAR; and* On 04/21/22 one dose of Lorazepam was signed out on the disposition log at 5:25 pm but was not signed as given on the MAR until 7:25 pm. Comparison of the medication dosing cards showed the amount of medication left was reflected accurately on the logs. The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 17 (MC Administrator) on 05/04/22. No additional documentation was provided, the staff acknowledged the findings.

Based on interview and record review, it was revealed the facility failed to ensure that 3 of 3 newly hired staff (#s 7, 8 and 13) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Review of staff training records on 05/03/22 revealed Staff 7 (CG/MT) hired 01/11/22, Staff 8 (CG/MT) hired 02/02/22 and Staff 13 (CG/MT) hired 02/02/22 lacked documented evidence of competency within 30 days of hire in the following required areas:* Roll of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Duties of the medication technician. The need to ensure competency was determined in all required areas within 30 days of hire was discussed with Staff 17 (MC Administrator) and Staff 11 (Health Services Director/RN) on 05/04/22. They acknowledged the findings.

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 C270 and C302.