Monarch Gardens Memory Care

Survey KIT004995

2 Deficiencies

Date: 6/17/2025

Type: Kitchen

Citations: 2

Citation #1: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:

t Visit: 6/17/2025 | Not Corrected

1 Visit: 10/22/2025 | Not Corrected

Regulation:

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).

Inspection Findings:

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

Observations of the kitchen on 06/17/25 showed the following areas needed cleaning or repair:

* Sections of flooring throughout the kitchen and dry storage had dark stains, black accumulation along the edges of baseboards and flooring, pieces of flooring were cracked and/or missing pieces and were pulling apart at seams. Patches to the flooring were pulling apart at edges and creating gaps in the floor;
* Dry storage shelving had spills and debris on multiple shelves and debris was noted underneath the shelving units;
* Refrigerator units were noted with spills and debris on the shelves and on bottoms of the units;
* Spills and splatters were noted on the large three-door refrigerator doors and vents, and a broken handle was noted on the center unit refrigeration side;
* Numerous lights in the kitchen had dead bugs, debris and/or dust gathered in the interiors;
* Four cutting boards were extremely worn and frayed, two mixing spatulas were missing small pieces and cracked, and two blender pitchers were cracked and stained;
* Debris, spills and discolored flooring was noted between and around equipment edges throughout the kitchen;
* Splatters were noted on the ceiling near the steam table and stove area. Large amounts of dust and webs were gathered on vents at the front of the kitchen and hanging from a video camera from the ceiling;
* Drains throughout the kitchen were darkly stained with black/brown accumulation and/or debris in the drain;
* Multiple plastic edge coverings and plastic wall pieces were cracked and missing large pieces near the window and the handwashing sink;
* Spills and splatters were noted on walls throughout the kitchen and along the fronts of both ovens; and
* An air conditioning wall unit, above the window, had thick dark accumulation and dust on the inner vent slats.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 2 (Facility Services Director) on 06/17/25. 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:

Plan of Correction:

1. Damaged Flooring – Seams Pulling Apart and Gaps Forming
• Corrective Action Taken: New flooring has been ordered. Kitchen flooring will be patched as an interim fix.
• Systemic Change: Ongoing monitoring and preventative maintenance will be implemented to detect early signs of flooring damage and address them promptly.
• Evaluation Frequency:
Monthly inspections by Maintenance or Executive Director (ED).
Weekly observations by Dining Services Manager (DSM).
• Responsible Party: Maintenance Director, Dining Services Manager, and Executive Director.

2. Dry Storage Shelving – Debris on Shelves and Underneath
• Corrective Action Taken: Shelving and surrounding area will be fully cleaned by Dining Department staff by 8/10/2025.
• Systemic Change: Routine cleaning schedule reinforced and documented in daily cleaning logs.
• Evaluation Frequency:
Weekly checks by DSM.
Monthly audits by DSM or ED.
• Responsible Party: Dining Services Manager, with oversight by Executive Director.

3. Refrigerator Door and Handle – Spills and Spatter Present
• Corrective Action Taken: Area has been cleaned. Door and handle will be replaced.
• Systemic Change: Added to daily cleaning checklist. Shift lead cooks verify cleaning at close of each shift.
• Evaluation Frequency:
Daily checks by cooks.
Weekly reviews by DSM.
Monthly audits by DSM or ED.
• Responsible Party: Cook staff, Dining Services Manager, Executive Director.

4. Ceiling Lights – Dust and Debris Present
• Corrective Action Taken: Lights cleaned by Maintenance on 7/8/2025.
• Systemic Change: Monthly maintenance schedule updated to include light cleaning in kitchen and food service areas.
• Evaluation Frequency:
o Monthly by Maintenance or ED.
• Responsible Party: Maintenance Director and Executive Director.

5. Cutting Boards and Mixing Spatulas – Damaged/Frayed
• Corrective Action Taken: Damaged items discarded on 6/17/2025. New equipment received on 6/30/2025.
• Systemic Change: Weekly supply checks implemented. Replaced items logged with date.
• Evaluation Frequency:
Weekly by DSM.
Monthly by ED.
• Responsible Party: Dining Services Manager, Executive Director.

6. General Cleaning – Spills, Spatter, and Debris in Kitchen
• Corrective Action Taken: Daily cleaning protocols are being enforced and documented.
• Systemic Change: Cleaning checklists are posted and signed off daily by cook staff and reviewed weekly.
• Evaluation Frequency:
Daily cleaning by cooks.
Weekly reviews by DSM.
Monthly spot checks by DSM and ED.
• Responsible Party: Cook staff, Dining Services Manager, Executive Director.

Citation #2: Z0142 - Administration Compliance

Visit History:

t Visit: 6/17/2025 | Not Corrected

1 Visit: 10/22/2025 | Not Corrected

Regulation:

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.

Inspection Findings:

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.

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:

Plan of Correction:

Refer to C240.

Survey PDY9

3 Deficiencies

Date: 5/15/2024

Type: State Licensure, Other

Citations: 4

Citation #1: C0000 - Comment

Visit History:

1 Visit: 5/16/2024 | Not Corrected

2 Visit: 9/9/2024 | Not Corrected

3 Visit: 1/13/2025 | Not Corrected

Inspection Findings:

The findings of the kitchen inspection conducted 05/15/24 through 05/16/24 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 revisit to the kitchen inspection of 05/16/24, conducted 09/09/24, 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 second revisit to the kitchen inspection of 05/15/24, conducted 01/13/25, 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 and OARs 411 Division 57 for Memory Care Communities.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:

1 Visit: 5/16/2024 | Not Corrected

2 Visit: 9/9/2024 | Not Corrected

3 Visit: 1/13/2025 | Corrected: 10/24/2024

Inspection Findings:

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the kitchen between 05/15/24 and 05/16/24 showed the following areas were in need of cleaning or repair.a. An accumulation of food spills, splatters, debris, dirt, dust, black matter, and grease was visible on or underneath the following:* Pipes, walls, and flooring behind/underneath the dish machine;* Floor drains;* Spice shelf and drawers;* Floors throughout the kitchen and dry storage had black matter build-up, food debris, and grease in corners, along baseboards, under equipment, and around perimeter edges;* Exterior of refrigerator and freezer doors; * Ice machine; and* Trash cans.b. Additional observations showed the following:* The air conditioning/heating unit mounted above the kitchen window had an accumulation of dirt, dust, and debris; * The kitchen window screen was not properly sealed to prevent containments and debris from entering the kitchen; * Water was leaking from the pipes on top of the dish machine during the rinse cycle;* The double countertop soup warmer was broken;* Cutting boards were heavily scored and stained;* The exterior of plastic bins containing flour, oats, and sugar had food spills and splatters and had cups or scoops stored in them; and* The reach-in refrigerators and freezers were overloaded with boxes and food items, making airflow difficult.The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) on 05/16/24. She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observations of the kitchen on 09/09/24 showed the following areas were in need of cleaning or repair:* Floors throughout the kitchen and dry storage had black matter build-up, black stains and/or food debris, along baseboards, under equipment, and around perimeter edges;* Flooring in the dry storage area had a large gap between two floor types which created a lip and a gap which debris and dirt were accumulated in. Two chunks of flooring were missing and a large section under the shelving was lifted off the floor;* The flooring in multiple areas of the main kitchen, including the office area, had cracks, gouges, scratches and/or seams that were pulling apart which allowed dirt and debris to accumulate. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 4 (Dietary Services Manager) on 09/09/24. The staff acknowledged the findings.

Plan of Correction:

Repair or Replacement-kitchen window screen1. Will be repaired by Maintenance Manager2. Dining Manager will ensure all items needing repaired are addressed with Maintenance Manager3. Maintenance Manager will inspect monthly with a monthly inspection list. 4. ED to monitor for completion during weekly 1:1 with both managers. -Water leak from top of dishwasher1. Maintenance Manager to contact repair company to repair this leaking pipe.2. Dining Manager to ensure items needing repaired are addressed with Maintenance Manager3.Maintenance Manager will inspect monthly with a monthly inspection list.4. ED to monitor for completion during weekly 1:1 with both managers.-Double Countertop Soup Warmer1. Replacements have been ordered and soup warmers disposed of.2. Dining Manager will ensure all items needing repaired or replaced are addressed with Maintenance Manager 3. Maintenance Manager will notify ED if replacement of item is needed.4. ED to monitor for completion of this purchase and will have weekly 1:1 meetings with both managers.-Cutting Boards1. Cutting Boards have been replaced with new professional grade boards.2. Dining Manager to ensure items needing repaired/replaced are being addressed with Maintenance Manager.3. Maintenance Manager to notify ED if replacement of items is necessary.4. ED to monitor for completion of this purchase and will have weekly meetings with both managers-Plastic Bins(containing dry goods)1. New plastic bins have been ordered to replace the aged ones2. Item was added to the Dining Managers checklist to ensure bins are not damaged or stained.3. Dining Manager will inspect these monthly and as needed.4. ED to ensure that Dining Manager is completing his weekly/monthly checklists with 1:1 weekly meetings.CLEANING AND SANITATION1. Staff will clean all spills, splatters debris, dust, black matter and grease from the air conditioning unit/heating unit, as well as the pipes and flooring behind the dish machine, floor drains, spice shelf and drawers, floors throughout the kitchen and dry storage, exterior of refridgerator and freezer doors, ice machine, and trash cans. 2. Daily/Weekly/Monthly cleaning lists have been updated to prevent violation from reoccuring.3. Cleaning list will be checked/evaluated daily/weekly/monthly as well as daily rounding by alternating managers. 4. Dining Service Manager will be responsible to see that tasklist/cleaning lists are completed daily/weekly/monthly while the ED will monitor Dining Service Manager weekly during 1:1 to assure proper cleaning and sanitationis complete as well as task/cleaning lists. Repair or Replacement -kitchen floor1. Will be repaired by Maintenance Manager with the assistance of the Regional Maintenance Manager and COO of Lenity. 2. ED, Kristine Smith, will ensure all items needing repaired/replaced are addressed with Maintenance Manager 3. Maintenance Manager will inspect monthly with the Dining Service Manager to ensure kitchen floor repairs are done in a timely manner. 4. ED to monitor for completion during weekly 1:1 with the MM.

Citation #3: C0455 - Inspections and Investigation: Insp Interval

Visit History:

2 Visit: 9/9/2024 | Not Corrected

3 Visit: 1/13/2025 | Corrected: 10/24/2024

Inspection Findings:

Based on observation and interview, 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 240.

Plan of Correction:

see C 240

Citation #4: Z0142 - Administration Compliance

Visit History:

1 Visit: 5/16/2024 | Not Corrected

2 Visit: 9/9/2024 | Not Corrected

3 Visit: 1/13/2025 | Corrected: 10/24/2024

Inspection Findings:

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.
Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 240.

Plan of Correction:

Refer to C 240see C 240

Survey KXED

17 Deficiencies

Date: 11/28/2023

Type: Validation, Change of Owner

Citations: 18

Citation #1: C0000 - Comment

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Not Corrected

Inspection Findings:

The findings of the change of ownership survey, conducted 11/28/23 through 11/30/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 revisit to the re-licensure survey of 11/30/24, conducted 05/15/24 through 05/16/24, 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, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Citation #2: C0231 - Reporting & Investigating Abuse-Other Action

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on interview and record review, it was determined the facility failed to investigate incidents to rule out abuse, document all required areas of an investigation, and/or report to the local Seniors and People with Disabilities (SPD) office if abuse could not be ruled out for 2 of 4 sampled residents (#s 1 and 3) reviewed for injuries of unknown cause, resident-to-resident altercations, and unwitnessed falls. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.A review of the resident's clinical record, including progress/observation notes, incident reports, and service plans dated between 09/09/23 to 11/27/23, and staff interviews identified the following:* 09/17/23 - Bruise to the right upper extremity;* 10/11/23 - Bruise on left upper extremity; and* 10/29/23 - Unwitnessed fall.There was no documented evidence the bruises or the unwitnessed fall had been investigated to rule out abuse or suspected abuse, nor evidence the local SPD was immediately notified of the incidents.During an interview on 11/29/23 at 12:32 pm, Staff 1 (ED) confirmed the incidents were not promptly investigated to rule out abuse or neglect and were not reported to the SPD office.The facility was requested to notify the SPD office of the incidents. Confirmation of the reporting was received on 11/30/23 prior to survey's exit.The need to immediately investigate injuries of unknown cause and unwitnessed falls to rule out abuse or suspected abuse and to notify the local SPD if abuse could not be ruled out was discussed with Staff 1 and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 04/2023 with diagnoses including dementia.A review of the resident's clinical record, including progress/observation notes, incident reports, and service plans dated between 09/02/23 to 11/27/23, and staff interviews identified the following: * 09/17/23 - Resident to resident altercation;* 09/18/23 - Staff to resident altercation;* 10/18/23 - Resident to resident altercation;* 10/28/23 - Resident to resident altercation; and* 11/19/23 - Resident to resident altercation. There was no documented evidence these incidents had been reviewed by the administrator. The need to ensure documented evidence of administrator review of incidents of abuse or suspected abuse was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Plan of Correction:

1. Incidents have been investigated and reported to APS for each incident. 2. Incidents will be reviewed daily by the clinical team (ED, RCC, RN, LPN) Investigations will be completed within 24 hours of incident. Once investigations are completed they will be emailed to ED to review and sign. 3. IR will be added to to daily, weekly and/or monthly checklists. will be discusssed during morning meeting or weekly 1:1's 4. Clinical Team (ED, RCC, RN, LPN)

Citation #3: C0252 - Resident Move-In and Eval: Res Evaluation

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#4) whose new move-in evaluation was reviewed. Findings include, but are not limited to:Resident 4 was admitted to the facility in 10/2023 with diagnoses including vascular dementia. Review of the record revealed the new move-in evaluation failed to address the following elements:* Customary routines, including sleeping, eating, and bathing;* Cultural preferences and traditions; * Personality, including how the person copes with change or challenging situations;* Pain, including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort;* Nutrition habits, fluid preferences and weight if indicated; and* History of dehydration. The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Plan of Correction:

1. Additional training on the completion of initial evals to be done with the LPN. LPN has been instructed to ensure all boxes are checked and a narrative for each portion of the evaluation/service plan to ensure step by step instructions for staff to care for resident. 2.RN and ED will review eval prior to moves in to ensure all areas have been completed. 3. Evals will be reviewed prior to each move in. Then every 30, 60, and 90 days. 4. Clinical Team (ED, RCC, RN, LPN)

Citation #4: C0260 - Service Plan: General

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident's service plan, last modified on 10/26/23, was reviewed, interviews with staff were conducted, and observations were made. The service plan was not reflective of the resident's needs and preferences and/or was not implemented in the following areas:* Pain, including the resident's non-verbal expressions of pain;* Evacuation status;* Preferences around room lighting and room temperature;* Divided plate and straws used with meals; and* Allergy / preferences regarding eggs.The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident preferences and needs and were implemented for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident's current service plan, last modified 11/15/23, was reviewed, interviews with staff were conducted, and observations were made. The service plan was not reflective of the resident's needs/preferences and/or was not implemented in the following areas:* Use of cane for mobility;* Use of dentures;* Evacuation instructions;* Hearing status and staff instructions; and* Behavior strategies from Behavior Support Services.The need to ensure service plans were reflective and implemented was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Plan of Correction:

1. Additional training on the completion of person centered service plans to be done with the LPN and RCC. LPN and RCC has been instructed to ensure all boxes are checked and a narrative for each portion of the evaluation/service plan to include resident prefrences and needs. 2.RCC, LPN, and ED to ensure adequate details are added to each service plan as well as step by step instructions for staff to follow. 3. Evals will be reviewed prior to each move in. Then every 30, 60, and 90 days. 4. Clinical Team (ED, RCC, RN, LPN) Additional training on the completion of person centered service plans have been done with the LPN and RCC. Resident 1- Care plan has been updated to include or update mobility, dentures, evacuations, and hearing status as well as to include staff instructions for each item. Resident 2 - Care Plan has been updated to include pain/expression of pain, evacuation status and room prefrences. Also staff instruction for each item.

Citation #5: C0270 - Change of Condition and Monitoring

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.The resident's current service plan, last modified on 10/26/23, Interim Service Plans (ISPs) dated 09/01/23 through 11/27/23, progress notes dated 09/01/23 through 11/27/23, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 11/28/23 and 11/30/23.a. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted, at least, weekly through resolution:* 09/23/23 - Runny nose and watery eyes;* 10/10/23 - Scooted out of wheelchair;* 10/11/23 - Bruise on left upper extremity;* 11/02/23 - Purple/red area on back from sitting on a birdhouse; and* 11/20/23 - Diarrhea episodes.b. The following changes of condition lacked documented evidence they were monitored, at least weekly, through resolution:* 10/29/23 - Redness and bruising following a fall.The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. She acknowledged the findings.
3. Resident 4 was admitted to the facility in 10/2023 with diagnoses including vascular dementia and generalized weakness.The resident's clinical record, including progress notes, was reviewed, and interviews were conducted. The following was revealed:a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and the communication of the determined actions or interventions to staff on all shifts:* 10/18/23 - Resident found on floor;* 10/25/23 - Nosebleed; and* 11/27/23 - Nosebleed. b. The following short-term changes of condition lacked progress noted, at least weekly, through resolution:* 10/16/23 - Wound to left buttocks; and* 11/03/23 - Resident moved units, monitor for any concerns related to change.The need to ensure actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure actions or interventions determined for changes of condition were documented and communicated to staff on each shift and monitored weekly until the condition was resolved for 3 of 4 sampled residents (#s 1, 2, and 4) with short-term changes of condition. Findings include but are not limited to:1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including dementia. Resident 2's clinical record was reviewed for changes of condition and revealed the following:On 10/18/23, Resident 2 was placed on alert charting for redness to his/her groin area. During an interview on 11/29/23 Staff 11 (CG) reported Resident 2 no longer had any redness to his/her groin area. There was no documented evidence the facility had monitored the change of condition through resolution.On 11/30/23, the need to ensure residents who experienced a change of condition were monitored until resolution was discussed with Staff 1 (ED). She acknowledged the findings.

Plan of Correction:

- 1. Adequate documentation and resolution to be added to the short term changes. 2. All potential short term or significant change in conditions will be reviewed by reading the observation notes daily. Any changes or concerns will be sent to the RN and LPN to review. 3. Daily by the administrator reading all of the observation notes. This will also will be added to daily/weekly checklist to ensure ISP and Alert Charting are completed as well as weekly monitoring and resultions by the nursing team. 4. Clinical Team (ED, RCC, LPN, RN) For short tem and and significant change of conditions appropriate documentation has been added for residents 1, 2 and 4 as well as added to weekly observation/checks. LPN or Rn to provide resolution note and take off weekly checks once resolved.

Citation #6: C0303 - Systems: Treatment Orders

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.Resident 1's MAR dated 11/01/23 through 11/27/23, corresponding progress/observations notes, and current physician's orders were reviewed. The resident's physician prescribed the following medications:* Senna/docusate 8.6-50 mg - Take one tablet by mouth two times daily for constipation. Hold for loose stools; and* Loperamide 2 mg - Take two tablets by mouth initially, then one tablet with each loose stool as needed for diarrhea.Resident 1's observation notes revealed the following:* 11/05/23 - "Very watery BM [bowel movement] twice during AM shift"; * 11/20/23 - "This morning during rounds resident also had diarrhea"; and * 11/20/23 - "During rounds after lunch, resident had diarrhea."The facility did not hold the senna/docusate per the physician's order on 11/05/23 and on 11/20/23. Additionally, the facility did not administer the loperamide per the physician's order on 11/05/23 and on 11/20/23.The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 5) whose medication orders were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident's 11/01/23 to 11/27/23 MARs and physician orders, dated 10/27/23, were reviewed.The resident had an order for Novolog (for lowering blood sugar) that instructed staff to notify the prescriber if the resident's CBG reading was over 351. Staff documented CBG readings over 351 on eight occasions from 11/01/23 to 11/27/23. There was no documented evidence the prescriber was notified on any occasion. During an interview at 9:25 am on 11/29/23, Staff 14 confirmed there was no documentation the prescriber was notified of the resident's CBG readings over 351.The need to ensure orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Plan of Correction:

1. In depth MT training to ensure all MT's are completing medication and treatment orders. Complete MAR audit to be completed. 2. Staff are instructed and trained to notify the clinical team of any medication / treatment orders. Staff continue to follow 3 Step medication approval. 3. Monthly MAR audits to be completed as well as any medication/treatment orders to be addressed when sending the 90 day orders. 4. MT's, and Clinical Team (ED, RCC, LPN, RN) In depth training to be provided. Residents 1 and 5 PCP has been faxed, Staff has faxed PCP regarding previous missed notifications. PCP is also being faxed to update for resident 1. Med changes have since been made.

Citation #7: C0305 - Systems: Resident Right to Refuse

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified if a resident refused consent to an order for 2 of 3 sampled residents (#s 1 and 2) who had documented medication and treatment refusals. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.The resident's MAR dated 11/01/23 through 11/27/23, and current physician orders were reviewed. Facility staff documented Resident 1 refused the following orders on 11/24/23: * Acetaminophen (a pain reliever);* Melatonin (a sleep aid);* Mirtazapine (for appetite);* Multivitamin (a supplement); and* Senna (for constipation).On 11/28/23 at 3:30 pm, Staff 3 (RCC) confirmed there was no documented evidence the facility notified Resident 1's physician of the refusals.The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (ED) and Staff 3 on 11/30/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 01/2021 with diagnoses including dementia. Resident 2's signed physician orders and 11/01/23 through 11/27/23 MAR were reviewed. The facility failed to provide documented evidence Resident 2's physician was notified related to the following medication and treatment refusals:* On 11/14/23: Amlodipine (for blood pressure), Divalproex (for seizures), multivitamin with minerals (a supplement), quetiapine (a mood stabilizer), and sertraline (a mood stabilizer), and levetiracetam (for seizures);* On 11/17/23: Amlodipine, Divalproex, multivitamin with minerals, quetiapine, sertraline, levetiracetam, and nystatin ointment (for yeast infection);* On 11/22/23: Nystatin ointment; and* On 11/27/23: Nystatin ointment.On 11/30/23, the need to notify the physician when a resident refused consent to an order was discussed with Staff 1 (ED). She acknowledged the findings.

Plan of Correction:

1. PCP will be faxed regarding all missed medications 2. New forms to be faxed to pcp for notification of missed medications to determine when the pcp would like to be faxed. Once fax is returned, RN will add when to notify to the MAR. Form to be utilized for all residents. Missed medication form to be pulled weekly to assure compliance with any missed medications for the week and to assure notifications were completed.3. PCP notification form to be reviewed or sent upon move in, frequent missed medications, or during 90 day eval. 4. MT, and Clinical Team (ED, RCC, LPN, RN)

Citation #8: C0330 - Systems: Psychotropic Medication

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including anxiety.Review of Resident 1's MAR dated 11/01/23 through 11/27/23, corresponding progress/observation notes, and physician orders revealed the following:Resident 1 was prescribed and received PRN lorazepam (for anxiety or agitation) on two occasions between 11/05/23 and 11/17/23. The facility lacked documented evidence non-pharmacological interventions were attempted and determined to be ineffective prior to administration of the lorazepam.On 11/30/23, Staff 14 (MT) reported the facility's electronic MAR system does not prompt staff to document the non-pharmacological interventions attempted prior to administering psychotropic medications, and staff were expected to document in the observation notes. Staff 14 confirmed no additional information was documented in the facility's observation notes when Resident 1 received the two doses of lorazepam. The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions were attempted with ineffective results prior to the administration of a PRN psychotropic medication for 2 of 2 sampled residents (#s 1 and 6) who were prescribed a PRN psychotropic medication. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 06/2020 with diagnoses including dementia.Resident 6 was prescribed PRN alprazolam for anxiety. Review of Resident 6's 11/01/23 through 11/27/23 MAR showed the PRN alprazolam was given on 10 separate occasions without documented evidence the facility had attempted non-drug interventions with ineffective results prior to administration of the medication. On 11/30/23, the need to ensure staff documented non-pharmacological interventions as ineffective prior to administering a PRN psychotropic medication was discussed with Staff 1 (ED). She acknowledged the findings.

Plan of Correction:

1. Additional training and updates made to care plan to list non-pharmacological interventions2. MT's are to ensure that care staff or themselves have attempted and completed non-pharmacological interventions, interventions have been documented prior to adminsitration of PRN. Monthly review by clinical team of all PRN Administrations to assure compliance. 3. At least weekly, and monthly during MAR Audit. 4. MT, and RCC

Citation #9: C0420 - Fire and Life Safety: Safety

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted every other month and included documentation of all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills. Findings include, but are not limited to: Facility fire drill records dated 06/2023 through 11/2023 were reviewed with Staff 1 (ED) on 11/30/23. The facility lacked documented evidence unannounced fire drills were conducted every other month and included the following components:* Date and time of fire drill;* Location of simulated fire origin;* Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the fire drills;* Evacuation time needed; and* Number of occupants evacuated.In addition, the facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills. The need to ensure unannounced fire drills were conducted and documented every other month and included all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills was discussed with Staff 1 (ED) on 11/30/23. She acknowledged the findings, and no additional documentation was provided.

Plan of Correction:

1. Fire and Elopement drills to be held every 90 days. The last one was completed in October 2023, the next will be completed in Dec 2023. 2. The system will be corrected by implementing a new schedule at the beginning of the year to follow what month the drill should be completed, and which shift. Added to daily/weekly checklist. As well as discussed during weekly meetings. 3. daily/weekly and yearly plan 4. Facilities director is responisble to ensure fire and elopment drills are completed on alternative months. ED to ensure they are completed by Facilities director. 1. Fire and Elopment drills will be completed every 60 days. The last one was completed in October 2023, the next will be completed in Dec 2023.

Citation #10: C0422 - Fire and Life Safety: Training For Residents

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:The facility's fire and life safety records were reviewed on 11/30/23.There was no documented evidence residents were provided fire and life safety procedure training within 24 hours of admission to the facility or were being re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.The need for residents to be instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (ED) on 11/30/23. She acknowledged the findings, and no additional documentation was provided.

Plan of Correction:

1. Annual fire and life training to be completed with all current residents by 12/31 to be in compliance for the 2023 year and then scheduled for the following year. 2. The system will be corrected by adding the training to our yearly plan. New form implemented to track this requirement and assure compliance.3. Added to daily/weekly and yearly plan to ensure completion. 4. Facilities to ensure fire and life training is completed within 24 hours of initial move in and annually. ED to ensure they are completed by Facilities director.

Citation #11: C0513 - Doors, Walls, Elevators, Odors

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on observation and interview, it was determined the facility failed to ensure the facility was free of unpleasant odors. Findings include, but are not limited to:Observations of the Monarch memory care unit from 11/28/23 through 11/30/23 revealed a strong, pervasive urine odor detected inside and in the hall near Room 227.On 11/30/23, the need to ensure the facility was free from unpleasant odors was discussed with and observed by Staff 1 (ED). She acknowledged the findings.

Plan of Correction:

1. Additonal cleaning supplies and updates made to resident care plan to ensure room is free of odors. Fax for bedside commode to assist with resident urinary issues. 2. Additional training to be done for daily manager rounding. Checking for upleasent odors or smells every morning. 3. Added to daily maanger rounding 4. ED, RCC, DSM, LEM, FD , all staff

Citation #12: C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:Observations from 11/28/23 through 11/29/23 revealed exit doors to the interior courtyards of the Garden and Monarch memory care units failed to have an alarm or other acceptable system to alert staff when residents entered and exited the courtyard. On 11/29/23, the need to ensure exit doors were equipped with an audible alarm or other acceptable system was discussed with Staff 1 (ED) and Staff 8 (Facilities Services Aide). They acknowledged the findings.

Plan of Correction:

1. Alarms were added to the exit doors to ensure there is proper notification. This was completed on 11.30.2023. 2. Facilities director will ensure alarm is in working condition. 3. Monotring of door alramrs to occure daily/week. Added to checklist. 4. FD, ED to ensure completed.

Citation #13: Z0142 - Administration Compliance

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Plan of Correction:

Refer to C231, C420, C422, C513, C555

Citation #14: Z0155 - Staff Training Requirements

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff completed all required pre-service orientation and dementia training topics prior to beginning job duties. Findings include, but are not limited to:Staff training records were reviewed on 11/29/23 at 1:00 pm. a. There was no documented evidence Staff 9 (Housekeeping), Staff 10 (CG), Staff 13 (MT), or Staff 18 (Cook), hired 10/04/23, 10/20/23, 10/06/23 and 09/13/23, respectively, completed Infectious Disease Prevention training prior to beginning their job duties. b. There was no documented evidence Staff 10 or Staff 13 completed the following dementia care training topics prior to providing resident care and services independently:* Environmental factors which are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and * Use of supportive devices with restraining qualities in the memory care communities. The need to ensure all staff training was completed in the required time frames was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Plan of Correction:

1. Currently working on receiving an updated training plan and add to Relias. 2. We will have an updated training list to folow that is reflective of state requirements. 3. Training plans and updates checked weekly, added to BOM weekly checklist. 4. To be completed by BOM and ED to ensure completed.1. Infectious diseas prevention training have been assigned to all staff and due to be completed by 01.28.2023. We are also currently working on an updated training plan to add to our Relias.

Citation #15: Z0162 - Compliance With Rules Health Care

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection 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 C252, C260, C270, C303, C305, and C330.

Plan of Correction:

Refer to C252, C260, C270, C303, C305, C555

Citation #16: Z0163 - Nutrition and Hydration

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident's current service plan, last updated 10/26/23, was reviewed, interviews with staff were conducted, and observations were made. The resident's service plan lacked a nutrition and hydration plan based on the resident's preferences and needs in the following areas:* Food and drink preferences;* Adaptive equipment used during meals; and* Instructions to staff when the resident did not wake for meals.The need to develop and document in the service plan an individualized nutritional plan addressing the resident's preferences and needs was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 10/2023 with diagnoses including vascular dementia. The resident's current service plan was reviewed, interviews with staff were conducted, and observations were made. The resident's service plan lacked a nutrition and hydration plan based on the resident's preferences and needs in the following areas: * History of dehydration; and* Favorite foods and liquids.The need to develop and document in the service plan an individualized nutritional plan addressing resident's preferences and needs was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.
4. Resident 2 was admitted to the facility in 01/2021 with diagnoses including dementia. The resident's current service plan was reviewed, interviews with staff were conducted, and observations were made. The resident's service plan lacked a nutrition and hydration plan based on the resident's preferences and needs in the following areas:* History of dehydration; and* Favorite foods and liquids.On 11/30/23, the need for individualized nutrition and hydration plans was discussed with Staff 1 (ED). She acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to document a daily meal program for nutrition and hydration based on the resident's preferences and needs in the service or care plan for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident's current service plan was reviewed, interviews with staff were conducted, and observations were made. The resident's service plan lacked a nutrition and hydration plan based on the resident's preferences and needs in the following areas:* History of dehydration;* Favorite foods and liquids; and* Feeding abilities, including how the resident's visual deficits impact his/her ability to self-feed.The need to ensure documentation in the service plan of a daily meal program based on the resident's preferences and needs was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Plan of Correction:

1. Service Plan and Care Plan to be updated to in clude an individualized nutrition plan for each resident. 2. Service/Care Plan to address history, likes & dislikes, etc. Clinical team will update current care plans to be reflective of nutritional needs, likes, and dislikes. 3. Initally, then 30, 60, and 90 days and every 90 dyas thereafter. 4. Clinical Team (ED, RCC, RN, LPN)

Citation #17: Z0164 - Activities

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:Residents 1, 2, 3, and 4's records were reviewed during the survey. a. There was no documented evidence an activity evaluation had been completed to reflect one or more of the following required components:* Current abilities and skills;* Emotional and social needs and patterns;* Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.b. There was no individualized activity plan developed for the sampled residents. On 11/30/2023, the need to evaluate each resident for activities, with all requirements addressed, and develop individualized activity plans was discussed with Staff 1 (ED). She acknowledged the findings.

Plan of Correction:

1. Service Plan and Care Plan to be updated to in clude an individualized acitivity plan for each resident. 2. Service/Care Plan to address history, likes & dislikes, etc. Life enrichment manager or Clinical team will update current care plans to be reflective of activity needs, likes, and dislikes. 3. Initally, then 30, 60, and 90 days and every 90 dyas thereafter. 4. Clinical Team (ED, RCC, RN, LPN)

Citation #18: Z0168 - Outside Area

Visit History:

1 Visit: 11/30/2023 | Not Corrected

2 Visit: 5/16/2024 | Corrected: 1/28/2024

Inspection Findings:

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to:Observations of the Garden and Monarch memory care units, from 11/28/23 through 11/29/23, revealed interior courtyard doors were locked, preventing residents from entering and exiting without staff assistance. There were no observations of inclement weather during that time.On 11/29/23 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED) and Staff 8 (Facilities Services Aide). They acknowledged the findings.

Plan of Correction:

1. Exit doors are to remain unlocked unless during inclement wheather 2. Doors will be checked daily during morning manager rounding. 3. Added to FD daily/weekly checlist to ensure process is being evaluated. 4. ED, RCC, DSM, BOM, LEM, FD. All staff

Survey MR7W

2 Deficiencies

Date: 4/5/2023

Type: State Licensure, Other

Citations: 3

Citation #1: C0000 - Comment

Visit History:

1 Visit: 4/5/2023 | Not Corrected

2 Visit: 8/30/2023 | Not Corrected

Inspection Findings:

The findings of the kitchen inspection, conducted on 04/05/23, 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 re-visit to the kitchen inspection of 04/05/23, conducted 08/30/23, 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.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:

1 Visit: 4/5/2023 | Not Corrected

2 Visit: 8/30/2023 | Corrected: 6/4/2023

Inspection Findings:

Based on observation and interview, it was determined the facility failed to maintain the kitchen clean and in good repair in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:The kitchen was toured on 04/05/23. An accumulation of food spills, splatters, loose food debris, dirt, dust, black matter, and grease was visible on or underneath the following:* Pipes and walls under the dishwasher;* Shelves and shelving units;* Mop sink;* Window sill; * Utility/Dish carts;* Laminated wall signs;* The tracks of the chest freezer;* Doors, door frames, thresholds;* Buildup of grease on the grill; * Buildup of dust on the fans in the refrigerators; and* Dense black matter and smudges on the flooring throughout the kitchen, with increased density by bases and edges of walls, appliances, shelving units, and food preparation tables. The following areas were in need of repair or replacement: * The caulking around the dish machine area had a buildup of black matter;* A square metal floor trap between the dishwasher and triple sink had brown/black matter on it and rust was developing;* The coating on multiple wire refrigerator shelves had peeled off and rust was developing;* Overhead light fixtures by the back door and between the stove and the pass-through windows were missing their covers;* Multiple cutting boards were heavily scored and discolored;* There were cracks, chips, and areas where the linoleum flooring had separated observed in the dry storage closet, by the entrance doors, and by the stand refrigerators; * There were multiple gouges and chipped paint on the walls throughout the kitchen;* A hand held metal sifter and potato masher had areas where rust had developed;* The test strips for the sanitation buckets had expired in 2020 and did not work properly;* The wall covering above the pass-through window had separated from the wall; and* The painted shelves in the dry storage had areas where the paint had peeled or worn off and raw wood was exposed. The need to maintain the kitchen clean and in good repair in accordance with the Food Sanitation Rules, OAR 333-150-000 was discussed with Staff 1 (Administrator) and Staff 2 (Dietary Director) on 04/05/23. They acknowledged the findings.

Plan of Correction:

Cleaning & Sanitation: 1. Staff will clean all spills, splatters, debris, dust, etc. - wooden shelving removed to be replaced w/ wire shelving 2. Daily, Weekly, and Monthly cleaning lists have been updated to prevent violation from reoccuring. - pipes, walls, window sill, utility/dish carts, wall signs, fridges and freezer tracks, doors, and grill all updated on cleaning lists 3. Cleaning list will be checked/evaluated daily, weekly, and monthly as well as daily rounding by alternate managers. 4. Dining Service Manager will be responsible to see that tasklist/cleaning lists are completed daily, weekly, and monthly while the executive director will monitor Dining Service Manager weekly during 1:1 to assure proper cleaning and satiation is complete as well as taks/cleaning lists. Repair or Replacement -Caulking 1. Will be repaired by Maintenance Manager. 2. Dining Manager will ensure all items needing replaced or repaired are addressed with Mainintenace Manager. 3. Maintenance Manager will inspect monthly with monthly Inspection Checklist. 4. ED to monitor for completion during weekly 1:1 with both Dining and Maintenance Managers. -Square Metal Floor Trap 1. Metal trap will need to be replaced by Maintenace Manager. 2. Item was added to monthly checklist to ensure grease traps or water drains are not damaged or rusted. 3. To be completed during monthly inspection. 4. Dining Manager will be responsible to see that inspection is completed monthly, ED to monitor weekly during 1:1. - Coating on wire refridgerator racks 1. Dining manager will order new racks for the refridgerator. 2. Item was added to monthly checklist to be inspected for rust, peeling paint, and damages. 3. To be completed during monthly inpspection. 4. Dining Manager will be responsible to see that inspection is completed - Overhead light fixtures 1. Maintenance Manger will order new covers. 2. Item is on monthly inspection checklist to ensure lights/fixtures are not in need of repair/cleaning. 3. To be completed during monthly inspection. 4. Maintenace manager to ensure corrections are completed, ED to moonitor for completion during weekly 1:1's - Fooring 1. Maintenance manager will replace flooring where damaged. 2. Item is on monthly inspection checklist to ensure lights/fixtures are not in need of repair/cleaning. 3. To be completed during monthly inspection. 4. Maintenance manager to ensure corrections are completed, ED to moonitor for completion during weekly 1:1's - Cutting Boards/ Kitchen utenisils, small equipment 1. All old, stained, damaged cutting boards thrown away. 2. Dining Manager will ensure inpsection of all utensils or small kitchen equipment is done weekly or monthly. Any items needing replaced will be added to the weekly department order form. 3. To be completed during monthly inspections. 4. Dining Manager will be responsible to see that inspection is completed, ED to monitor for completion during 1:1's. - Sanitation Test Strips. 1. New strips have been ordered and delivered. 2. Dining manager will check test strips weekly and and to order if needed. 3. Added to monthly inspection to ensure strips have not expired. 4. Dining Manager will be responsible to see that inspection is completed, ED to monitor for completion during 1:1's. - Wall coverings 1. Maintenance will replace 2. Item is on monthly inspection checklist to ensure walls are not in need of repair/cleaning. Dining will report any damages promptly to Maintenane Manager. 3. To be completed during monthly inspections. 4. Maintenace manager to ensure corrections are completed, ED to moonitor for completion during weekly 1:1's - Painted/Wood Dry Storgae Shelves. 1. New wire/metal shelves have been ordered and delivered on 04/12/2023. Wooded Shelveds will be removed and replaced. 2. Item was added to monthly checklist to be inspected for rust, peeling paint, and damages. 3. To be completed during monthly inpspection. 4. Dining Manager will be responsible to see that inspection is completed

Citation #3: Z0142 - Administration Compliance

Visit History:

1 Visit: 4/5/2023 | Not Corrected

2 Visit: 8/30/2023 | Corrected: 6/4/2023

Inspection Findings:

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 C 240.

Plan of Correction:

Refer to C 240

Facility Information

Violations

Notices

Survey History

Survey KIT004995

Citations: 2

Citation #1: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:

Regulation:

Inspection Findings:

Plan of Correction:

Citation #2: Z0142 - Administration Compliance

Visit History:

Regulation:

Inspection Findings:

Plan of Correction:

Survey PDY9

Citations: 4

Citation #1: C0000 - Comment

Visit History:

Inspection Findings:

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:

Inspection Findings:

Plan of Correction:

Citation #3: C0455 - Inspections and Investigation: Insp Interval

Visit History:

Inspection Findings:

Plan of Correction:

Citation #4: Z0142 - Administration Compliance

Visit History:

Inspection Findings:

Plan of Correction:

Survey KXED

Citations: 18

Citation #1: C0000 - Comment

Visit History:

Inspection Findings:

Citation #2: C0231 - Reporting & Investigating Abuse-Other Action

Visit History:

Inspection Findings:

Plan of Correction:

Citation #3: C0252 - Resident Move-In and Eval: Res Evaluation

Visit History:

Inspection Findings:

Plan of Correction:

Citation #4: C0260 - Service Plan: General

Visit History:

Inspection Findings:

Plan of Correction:

Citation #5: C0270 - Change of Condition and Monitoring

Visit History:

Inspection Findings:

Plan of Correction:

Citation #6: C0303 - Systems: Treatment Orders

Visit History:

Inspection Findings:

Plan of Correction:

Citation #7: C0305 - Systems: Resident Right to Refuse

Visit History:

Inspection Findings:

Plan of Correction:

Citation #8: C0330 - Systems: Psychotropic Medication

Visit History:

Inspection Findings:

Plan of Correction:

Citation #9: C0420 - Fire and Life Safety: Safety

Visit History:

Inspection Findings:

Plan of Correction:

Citation #10: C0422 - Fire and Life Safety: Training For Residents

Visit History:

Inspection Findings:

Plan of Correction:

Citation #11: C0513 - Doors, Walls, Elevators, Odors

Visit History:

Inspection Findings:

Plan of Correction:

Citation #12: C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable