Avamere at Hillsboro

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).

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OARS 333-150-000. Findings include, but are not limited to: The kitchen and MCC kitchenette were toured at 11:17 am on 07/01/25. The following was identified: a. The following areas were in need of cleaning: * A build-up of dust was observed on the galvanized metal shelving, the exterior of the ice maker, and the ceiling; * A build-up of grease drips was observed on the sides of the fryer; * The dry storage bins containing sugar, flour, and oats had a build-up of grime on the exterior; * The main kitchen doors and frames had chipped paint and black scuff marks; and * The MCC kitchenette refrigerator interior, floors, walls, and cupboard exteriors had a build-up of food spills and debris. b. The following items were in need of repair: * Baseboard was missing along the bottom of the wall in front of the hot food pass and on the bottom corner next to the oven; * The plastic cold food prep board was worn with deep grooves and plastic chipped off; * A rubber spatula was worn with pieces chipped off; and * The laminate wall below the hot food station had worn/chipped pieces and metal peeling back rendering it uncleanable. c. Staff beverages were observed on the shelf of the hot food service station directly above an uncovered cake intended to be served to residents. Surveyor requested the beverages be removed. d. Staff did not have alcohol wipes available to use for food temping thermometers. e. Staff were observed delivering meals to MCC resident rooms without covering beverages or soup. The above areas were toured with and/or reviewed with Staff 1 (ALF ED) at 12:45 pm on 07/01/25. She acknowledged the findings.

C0240 1. Weekly dusting schedule created and implemented. Daily walk through to be completed 5 times a week by the Dietary Manager. 2. Fryer having grease: Daily wipe down of the fryer. This will be completed by the cooks at the end of their shift. Dietary Manager and ED will monitor. 3. Dry storage bins: Storage bins will be wiped down daily by the cooks and monitored by the Dietary manager 5 days a week. 4. Kitchen door and frames chipped paint and black scuffs marks: Maintenance Director will paint over the doors and trim. Dietary Manager and ED will monitor this 5 days a week. Maintenance Director will complete touch up paint on-going. 5. MCC Kitchenette cleaning will be on a daily schedule monitored 5 days a week by MC Administrator 6. repairs needed: *Baseboard missing along the wall in front of the hot food pass, corner piece broken next to the oven. Repaired and replaced the strip. This will be monitored by the Dietary Manager twice monthly. *Plastic cold food prep board: board was replaced and will be monitored on-going by the cooks and Dietary Manager daily. *Rubber Spatula was removed and replaced. Daily monitoring of utentisils to be completed by Dietary Manager and cooks. *Laminate wall below the hot food station: New laminate applied to allow the surface to be cleanable, the metal peeling back was fixed. This will be monitored weekly by Dietary Manager and ED. 7. Staff beverages on shelf: Sign posted to not have beverages in the staff were notified of where they can place their beverages. This will be monitored daily by the cooks and the Dietary manager 8. Alcohol wipes ; Available to use for sanitizing food temperature. Staff have been given alcohol wipes instructed on when to notify the Dietay Manager when low. Dietary Manage will monitor 5 days a week . 9. MCC staff will cover all meals and beverages upon delivery of meal trays. Z0142 : Refer to above POC for C240

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).

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.

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 C 240.

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.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review, it was determined the facility failed to complete fire drills on alternate months and document all required components of fire drills. Findings include, but are not limited to: Fire drill records from 04/2024 through 09/2024 were reviewed on 09/12/24. The facility failed to document the following required components: * Date & 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 drills; * Evacuation time-period needed; * Staff members on duty & participating; and * Number of residents evacuated. There was no documented evidence fire drills were provided to staff on alternate months of fire and life safety training. On 09/12/24, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 3 (ED) and Staff 5 (Director of Maintenance). They acknowledged the findings.

1. Provided training to Maintenance Director on the requirement to document Fire Drills for Memory Care separate from Assisted Living and on the requirements for staff training on alternating months. A Memory Care specific fire drill was completed in September 2024 and included all required components. 2. TELs software used for scheduling maintenance tasks has been updated to populate Memory Care fire drills separate from Assisted Living so that tasks will require separate documentation. Maintenance Director has been provided with Fire Drill form which includes all necessary compoents required to document the drill. Monthly all staff meetings will include Fire and Life Safety trainings on alternating months. 3. TELs will be reviewed monthly to ensure schedule is being followed and all components are addressed. Staff training reviewed monthly. 4. Memory Care Administrator, Executive Director and Maintenance Director are responsible for maintaining this system.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse, and provided storage for maintenance equipment, including yard maintenance tools. Findings include, but are not limited to: The interior courtyard was toured on 09/09/24. The following was identified: * A large, opened bag of potting soil on the patio contained multiple pieces of litter. * A crumpled latex glove was observed in the bark mulch. * An upside-down stack of tomato cages, with metal ends sticking upright, was observed in the bark mulch. These findings were reviewed in a tour of the facility on 09/10/24 with Staff 1 (Administrator 1) and Staff 5 (Director of Maintenance). They acknowledged the findings.

1. Removed potting soil, trash and tomato cages from courtyard. Inservice conducted with all Memory Care staff on keeping the common areas free of trash and items which could potentially cause harm. 2. Current Memory Care team have been reeducated on maintaining a safe and clean environment for residents and training conducted upon new hire for new team members. Courtyard will be walked weekly to ensure no trash or harmful items are present. 3. Weekly walk through of Memory Care community and courtyard. 4. Executive Director, Memory Care Director, Maintenance Director

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to: During observations conducted 09/09/24 the following were found to need cleaning and/or repair: * Multiple door frames and doors throughout the facility had chips, gouges and/or scrapes; and * The window blinds in resident room 112B had multiple broken and crumpled slats. These findings were reviewed in a tour of the facility on 09/10/24 with Staff 1 (Administrator 1) and Staff 5 (Director of Maintenance). They acknowledged the findings.

1. Resident doors have been repaired and blinds in apartment 112B have been replaced. 2. Weekly walkthough of Memory Care with a focus on environmental ensuring community is clean and in good repair. Any areas identified as a concern will be corrected. All Memory Care staff have been reeducated on environmental expectations and to report any concerns to Maintenance Director and new employees will be trainined on this expectation during orientation. 3. Weekly walkthroughs. 4. Executive Director. Memory Care Director and Maintenace Director will be responsible for maintaining this system.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

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.

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 C420, C510, and C513.

See POC for C420, C510 and C513

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.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

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1. A complete audit was conducted for all training and competency records. All trainings and competencies will be complete and up to date for current employees. 2. To prevent recurrence, all staff will be required to complete the required training and job specific competencies within 30 days of hire. Incomplete trainings and competencies will be reviewed five days a week as part of daily standup meeting to identify missing components, to review the status of new hires' trainings to ensure all training is completed within 30 days of hire. 3. This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their required trainings. 4. The Executive Director and Business Office Manager will be responsible for maintaining this sytem.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

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 06/20/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * Flooring throughout kitchen - spills/food debris/dust/dirt - dishwashing area, under counters, next to ice cream freezer, between stove/oven & steam table, dry storage, walk in refrigerator; * Vents and surrounding ceiling - significant dust build up - above steam table, outside dry storage area, near ice maker; * Walls - dishwashing area - black matter around caulking, brown drips below shelf on dirty side, next to soup warmer, behind/above two door refrigerator; * Shelving above and below counters throughout the kitchen - food debris/dust/drips/spills - dishwashing area, prep counter with two drawers next to commercial mixer, prep counter near entrance to dining room; * Cart containing large container of grease with significant spills; * Interior of microwave - food splatter; and * Food bin lids and exterior - dry food debris. Improper food storage: * Refrigerated items open to air, not securely closed; * Refrigerated items not labeled/dated; * Uncovered salads on counter; * Onions and potatoes on floor in dry storage: * Open box of rice in dry storage; * Open undated bags of almonds and peanuts in dry storage; and * Food stored below sink next to sanitation bucket and unlabeled spray bottle. Other areas of concern: * Lack of thermometers in walk in refrigerator and small refrigerator on service line; * Dishwashing machine not meeting minimum temperature - maintenance checked and called vendor to check immediately. Facility to use three-compartment sink until dishmachine was reaching the required temperature; * Two uncovered garbage cans near dining entrance; * Very worn colored cutting boards - cuts/grooves - uncleanable; * Uncovered ceiling light; * Build up of ice preventing freezer door from closing completely; * Not using pasteurized eggs, PIC stated eggs were served over easy and sunny side up occasionally - encouraged to use eggs fully cook if cannot be returned for pasteurized eggs; and * Kitchen staff changing gloves on service line without washing hands between dirty and clean. The areas of concern were discussed and observed by Staff 1 (PIC/Cook) and discussed with Staff 2 (Business Office Manager) and Staff 3 (Corporate Staff) on 06/20/24. The findings were acknowledged.

Flooring and walls throughout the kitchen were professionally cleaned by Summit Facility Services on July 10th, 2024. Vents throughout the kitchen were cleaned and will be added to the monthly cleaning schedule in our building management system. This will be completed by the Director of Environmental Services. Shelving was cleaned and will be done weekly by dietary staff. The grease container cart was removed and oil storage buckets with closed lids and pour spouts were ordered. Microwave and food bins were cleaned. Ceiling tiles replaced. Food storage area was audited for open dates and proper storage was reviewed. Additional thermometers were ordered and are in place. Smart Care came to inspect the dishwasher on June 21st and found adequate temperatures were achieved after running 2-3 cycles. Signage added to dishwasher and dining staff trained on this requirement. Executive Director will look into availability of low temp sanitizer through our chemical vendor. Replacement  lids ordered and in place for trash bins. Cutting boards replaced. Ceiling light cover replaced. Maintenance request placed for freezer door inspection through Sunglow for review of seals and latches. Pasteurized Eggs to be ordered routinely, purchased locally if unavailable from preferred vendor. Dining staff educated on the requirements for eggs. Proper handwashing procedures reviewed with all dining staff. The findings of this survey were reviewed in entirety with the dining staff and retraining provided in areas needed. The Dining Services Director will complete an audit of all areas weekly and submit to the Executive Director for review. The Executive Director will audit monthly to ensure continuous quality improvement.

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 C 240.

see C 240

The findings of the kitchen inspection, conducted 06/20/24, 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 and OARs 411 Division 57 for Memory Care Communities. 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.

The findings of the re-visit to the kitchen inspection of 06/20/24, conducted 08/20/24, are documented in this report. The facility was found to be 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 ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main kitchen, memory care kitchenette, food storage areas, food preparation, and food service on 05/09/23 revealed the following: * Open packages of dry cereal stored on a shelf above clean dishes in the main kitchen food service area; * Garbage barrels used for food disposal did not have covers available when not in use; * Build up of food material on the grill surface and overflow drawer of the grill top; * Sanitizer buckets with cleaning cloths were tested using test strips and were shown to have a lower concentration of sanitizing chemical than the acceptable range on the test strip instructions; * The sanitizing solution distributed by the "Ecolab" dispenser installed above the three compartment sink was tested by kitchen staff, using the test strips, and showed the chemical sanitizer was below the acceptable range; * Cooked fish being stored in a warm oven, prior to serving, measured 120 degrees with a probe thermometer (below the required temperature of 135 degrees Fahrenheit); * One kitchen staff was observed without properly restrained hair while washing dishes and performing food preparation; * The refrigerator and freezer in the memory care kitchenette had dried spills and food particles on the shelves throughout; and * Direct care staff in the memory care unit, who were designated to also serve meals, did not have aprons to wear during food service tasks.   The following areas/items were in need of repair:   * Exposed wood surfaces, scuffs and blackened areas on the doors exiting the kitchen into the dining room; * Exposed wood surfaces and damage to the cabinets below the coffee and juice service areas in the dining room; and * The hot water sitting in hand washing sinks in the main kitchen needed an extended period of time, in excess of three minutes, for the water to get hot (temperature obtained was a maximum of 112 degrees Fahrenheit). During an interview on 05/09/23, Staff 2 (Human Resources Manager) provided copies of food handler certification cards for kitchen staff. A review of the records showed ten kitchen staff did not have a current food handler's card. Staff 2 acknowledged the findings. At 11:15 am, the above areas were discussed with Staff 1 (Kitchen Manager) and Staff 3 (Administrator). They acknowledged the findings.

Care staff and house keeping given instruction to deep clean kitchen 1x per week. Care staff to keep up with general daily cleaning tasks such as cleaning up spills, sweeping, mopping, sanitizing countertops and high contact areas. Full body aprons ordered for care staff whom are serving food. Staff to be trained on cleanthiness and expectations of daily upkeep of kitchen and common areas. Weekly Kora Greer- Memory Care Administrator

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: a. Observations of the main kitchen, memory care kitchenette, food storage areas, and food preparation on 06/20/23 revealed the following: * Garbage barrels used for food disposal (in the main kitchen and the memory care kitchenette) did not have covers available when not in use; * Staff food was stored in the refrigerator used for resident food in the memory care kitchenette; * Food items found in the refrigerator and freezer in the memory care kitchenette were not properly covered, labeled and/or dated; * The interior and exterior oven and countertops in the memory care kitchenette had dried spills and food particles; and * Direct care staff in the memory care unit, who were designated to also serve meals, did not have aprons to wear during food service tasks.   The following item was in need of repair:   * Two ceiling tiles above the three compartment sink were damaged. b. During an interview on 06/20/23, Staff 2 (Human Resources Manager) provided copies of food handler certification cards for kitchen staff. A review of the records showed Staff 5 (Dietary Server) did not have a current food handler's card. Staff 2 acknowledged the findings. At 11:40 am, the above areas were discussed with Staff 4 (Executive Director) and Staff 3 (Administrator in Training). They acknowledged the findings.

*Aprons have been provided to staff and are available for their use daily. Staff made aware that these are to be used when serving food to residents to reduce cross contamination.   *Garbage can with lid purchased for kitchen use in memory care. * There is seran wrap and a sharpie available to staff in the kitchen to ensure that items are covered and dated prior to being put into the fridge or freezer. Staff has been coached that foods that are not dated or covered are to be thrown out immediately. Staff has also been coached on personal lunches not being stored in memory care fridge/freezer, personal food and lunches are to go in break room fridge/freezer. If personal food is found in the freezer, it will be moved to break room immediately. The Arbor Admin will audit this weekly. * Oven and stove top has had a deep clean done by housekeeping crew and will be done weekly ongoing. Noc shift staff will do spot cleaning daily to maintain. Arbor Admin will audit this weekly.

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.

Refer to plan of correction for C 240.

Based on observation, interview and record review, 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.

see C 240

Based on interview, observation and review of documentation, 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.

see C 240

The findings of the kitchen inspection, conducted 05/09/23, 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 for the kitchen inspection on 05/09/23, conducted 06/20/23, 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 second re-visit of the annual kitchen inspection on 05/09/23, conducted 08/23/23, 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 interview and record review it was confirmed that the facility failed to notify a resident's emergency contact in an emergency. Findings include: During an interview on 11/15/2022, Staff #1 (S1) stated that there was a time when the facility forgot to notify the resident ' s emergency contact when the resident went to the hospital. A review of Resident #1 (R1) service plan dated 8/19/2022 and progress notes dated 9/2/2022-11/152022. The progress notes show that on 10/24/2022 that the emergency contact was not notified about their family member going to the hospital on 10/23/2022. On 11/15/2022, these findings were reviewed and acknowledged by S1. Plan of Correction: S1 had a re-education last week for informing family members or Power of Attorney (POA's) of residents when the resident is sent to the hospital.

Based on interview and record review it was confirmed that the facility failed to ensure only individuals with a diagnosis of dementia who are in need of support for the progressive symptoms of dementia for physical safety, or physical or cognitive function may reside in a memory care community. Findings include: During an interview on 11/15/2022 Staff #1 (S1) stated that Resident #1 (R1) had a diagnosis for dementia when living in the assisted living but admits that when R1 moved to memory care the facility could not find a formal diagnosis. A review of R1 service plan dated 8/19/2022 and progress notes dated 9/2/2022-11/15/2022 state no medical diagnosis found. On 11/15/2022, these findings were reviewed and acknowledged by S1. Plan of Correction: The RN has reached out to the resident 's doctor to see if she has a formal diagnosis. awaiting doctors'  response.