Maple Ridge Senior Living

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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 10/20/25, from 1:45 pm through 3:40 pm, the facility kitchen and the dining room were observed. 1. The following areas needed cleaning: • Coffee station cabinet, both inside and outside, was dirty with brown and black matter and visible spills; • Handwashing sink, especially around the faucet had a brown buildup; • Vent above the ice machine had accumulated dust; • Window screen had layers of spiderwebs; • Juice and cappuccino dispensers had sticky spills and residual buildup; • Walls throughout the kitchen had visible food debris and spills and stains particularly near the coffee maker and the rack for storing clean utensils; • The interior of the soup warmer had brown residue and rust, and the exterior was sticky to the touch; • Baseboards especially in the corners, had visible food debris and accumulated black and brown matter; • Trash cans exterior had layers of debris; • Sprinkler heads and surrounding ceiling areas had spiderwebs and black buildup; • Rack used for storing clean utensils, bowls, and dishes had visible dust; • Bulk containers had spills and food debris on the outside; • Floor behind the dry storage door and near the plastic rack had black residue and buildup; • Several dry food items including walnuts, cake mix, peanuts, and sunflower seed, were open and undated; and • The interior of the microwave had accumulated food debris. 2. The following items were in need of repair: • Caulking and wall around the dishwasher area had brown residue and accumulated black matter; • Several trays were dented and had brown buildup; • Colored cutting boards were heavily scored; • In the dry storage area, the walls and ceiling near the white shelving had multiple holes and cracks; and • Commercial can opener blade was worn and had black buildup. 3. Improper food storage: • Two-door refrigerator had several food items, including pasteurized liquid eggs, sliced cheese, dressings, sliced lemons, and juices were open, undated and not properly sealed; • Inside the one-door refrigerator, open containers of corn, cheese and meat were undated; • Walk-in cooler, several items including beans, corns and marinated meat were uncovered and undated; and • An open cup of juice was uncovered and undated. 4. Other areas of concern: • Three Red Bull cans containing beverages were observed on the storage rack near the entrance, and a staff member was seen drinking from them; • Mixer was uncovered when not in use; • A garbage can containing soda bottles had no cover or lid and flies were observed around the area; and • Several staff members in the kitchen were observed working without proper hair restraints. The areas of concern were reviewed with Staff 2 (Dining Service Director) and Staff 3 (Wellness Director) on 10/20/25 at 3:00 pm. They acknowledged the findings.

Plan of Correction for 11/2025 Survey • Full Kitchen Deep clean scheduled on 11/19, additional days to be scheduled if needed. • Daily/Weekly Cleaning Sheets to be reconfigured by 11/12 for Kitchen Team meeting. o Staff will be required to sign off when the task is completed followed by Cook on duty signing off before staff leaves from shift. o An attendance sheet will be signed by those who are in attendance, those who miss will follow up with DSD afterwards and sign off on date information discussed. • Kitchen staff will be assigned ServeSafe Training to complete by 11/30 and the Oregon Health Authority Foodborne Illness Prevention Program will be reviewed at staff meeting on 11/12 • Lists goal is to assign and track staff’s attention to the following: 1. The following areas needed cleaning: • Coffee station cabinet, both inside and outside, was dirty with brown and black matter and visible spills o Area will be deep cleaned on 11/19 o Front of house staff to clean and straighten 3 times a day after meal services Follow Up: • DSD to audit weekly • Administrator to spot check monthly for any signs of build-up • Handwashing sink, especially around the faucet had a brown buildup o Handwashing sink to be deep cleaned on 11/19 o Build-up is broken down glue, maintenance to recaulk sink o Handwashing sink to be cleaned weekly Follow Up: • DSD to audit monthly • Administrator to audit quarterly • Vent above the ice machine had accumulated dust o Vent cleaned on 11/22 o Staff to clean weekly Follow Up: • DSD to audit monthly • Administrator to audit quarterly • Window screen had layers of spiderwebs o Schedule to be cleaned during deep clean on 10/19 o Staff to clean weekly Follow Up: • DSD to audit monthly • Administrator to audit quarterly • Juice and cappuccino dispensers had sticky spills and residual buildup o Juice and cappuccino dispensers to be deep cleaned on 11/19 o Staff to clean daily Follow Up: • DSD to audit weekly • Administrator to audit monthly • Walls throughout the kitchen had visible food debris and spills and stains particularly near the coffee maker and the rack for storing clean utensils o Walls to be deep cleaned on 11/19 o Staff to clean daily Follow Up: • DSD to audit weekly • Administrator to audit monthly • The interior of the soup warmer had brown residue and rust, and the exterior was sticky to the touch o A new soup warmer will be purchased o Staff to clean daily Follow up: • DSD to audit weekly • Administrator to audit monthly • Baseboards especially in the corners, had visible food debris and accumulated black and brown matter o Baseboards and corners to be deep cleaned on 11/19 o Baseboard and floors to be cleaned bi-weekly Follow up: • DSD to audit weekly • Administrator to audit monthly • Trash cans exterior had layers of debris o Trash cans to be deep cleaned on 11/19, and replaced if needed after cleaning o Trash cans to be cleaned weekly by team Follow up: • DSD to audit weekly • Administrator to audit monthly • Sprinkler heads and surrounding ceiling areas had spiderwebs and black buildup o Sprinkler heads and surrounding areas cleaned by Maintenance on 10/28 o Team members to monitor weekly and alert maintenance if they need to be cleaned. Follow up: • DSD to audit weekly • Administrator to audit monthly • Rack used for storing clean utensils, bowls, and dishes had visible dust o Rack to be deep cleaned on 11/19 o Plastic cover for shelf purchased as barrier for clean dishes o Team to clean weekly Follow up: • DSD to audit monthly • Administrator to audit quarterly • Bulk containers had spills and food debris on the outside o Containers to be deep cleaned on 11/19 o Team to clean weekly, deep clean when refilling with product Follow up: • DSD to audit monthly • Administrator to audit quarterly • Floor behind the dry storage door and near the plastic rack had black residue and buildup o Full dry storage space to be deep cleaned on 11/19 o Dry Storage tidied biweekly on food order days, floors to be cleaned biweekly as well Follow up: • DSD to audit monthly • Administrator to audit quarterly • Several dry food items including walnuts, cake mix, peanuts, and sunflower seed, were open and undated o New containers to be purchased for products in dry storage o Staff to be retrained on open container and dating requirements o Team to audit dates daily throughout kitchen Follow up: • DSD to audit weekly • Administrator to audit monthly • The interior of the microwave had accumulated food debris. o Microwave deep cleaned on 10/29 o Team to clean microwave daily Follow up: • DSD to audit weekly • Administrator to audit monthly 2. The following items were in need of repair: • Caulking and wall around the dishwasher area had brown residue and accumulated black matter o Team began cleaning dish area on 10/27, will be deep cleaned on 11/19 o Maintenance to recaulk the area prior to compliance date o Team will clean weekly Follow up: • DSD to audit monthly • Administrator to audit monthly • Several trays were dented and had brown buildup o New trays purchased Follow up: • DSD to inventory monthly and replace as needed • Administrator to audit monthly • Colored cutting boards were heavily scored o New colored cutting boards purchased Follow up: • DSD to inventory monthly and replace as needed • Administrator to audit monthly • In the dry storage area, the walls and ceiling near the white shelving had multiple holes and cracks o Maintenance to repair holes and cracks by date of deep cleaning scheduled on 11/19 Follow up: • DSD to check kitchen monthly for maintenance repairs needed • Administrator to audit quarterly • The commercial can opener blade was worn and had black buildup. o New blades purchased o Team to check to see if it needs replaced weekly Follow up: • DSD to audit monthly • Administrator to audit quarterly 3. Improper food storage: • Two-door refrigerator had several food items, including pasteurized liquid eggs, sliced cheese, dressings, sliced lemons, and juices were open, undated and not properly sealed o All undated food discarded after survey was completed o Staff to be retrained on food storage and dating procedures at 11/12 kitchen meeting and ongoing as needed o Staff to check for dates daily as part of cleaning list Follow Up: • DSD to Spot Check Weekly • Administrator to spot check monthly • Inside the one-door refrigerator, open containers of corn, cheese and meat were undated o All undated food discarded after survey was completed o Staff to be retrained on food storage and dating procedures at 11/12 kitchen meeting and ongoing as needed o Staff to check for dates daily as part of cleaning list Follow Up: • DSD to Spot Check Weekly • Administrator to spot check monthly • Walk-in cooler, several items including beans, corns and marinated meat were uncovered and undated o All undated food discarded after survey was completed o Staff to be retrained on food storage and dating procedures at 11/12 kitchen meeting and ongoing as needed o New large storage bins with lids purchased for preparing food such as marinating meats o Staff to check for dates daily as part of cleaning list Follow Up: • DSD to Spot Check Weekly • Administrator to spot check monthly • An open cup of juice was uncovered and undated o Staff to be retrained on beverage storing procedures at 11/12 kitchen meeting and ongoing as needed o Staff to check for open containers daily as part of cleaning list Follow Up: • DSD to Spot Check Weekly • Administrator to spot check monthly 4. Additional observations: • Three Red Bull cans containing beverages were observed on the storage rack near the entrance, and a staff member was seen drinking from them o Staff to be retrained on employee beverage policy and procedures at 11/12 kitchen meeting and ongoing as needed, including the use of lids and straws o DSD to create designated drink area for employee drinks to comply with regulations Follow Up: • DSD to Spot Check Weekly • Administrator to spot check monthly • Mixer was uncovered when not in use o Mixer bowl to be stored upside down when not in use o Team to ensure in compliance during while going through daily cleaning lists Follow Up: • DSD to Spot Check Weekly • Administrator to spot check monthly • A garbage can containing soda bottles had no cover or lid and flies were observed around the area o All lids for garbage cans located and placed on corresponding garbage cans Follow Up: • DSD to Spot Check Weekly • Administrator to spot check monthly • Several staff members in the kitchen were observed working without proper hair restraints. o Multiple proper hair restraint options purchased for staff to utilize o Staff to be retrained on employee beverage policy and procedures at 11/12 kitchen meeting and ongoing as needed, including the use of lids and straws Follow Up: • DSD to Spot Check Weekly • Administrator to spot check monthly

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included documented reasons for use for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2024 with diagnoses including cerebrovascular accident and impaired cognition. The resident's current prescriber orders and 08/01/24 through 09/09/24 MARs were reviewed and the following medications lacked reasons for use: * Finasteride; * Tamsulosin; * Metoprolol succinate; * Buproprion HCL XL; * Levetiracetam; * Atorvastatin; * Cefdinir; * Fluoxetine; * Vazalore; * Aspirin EC; * Acetaminophen; * Senna; and * Bisacodyl. During an interview on 09/11/24 at 10:35 am, Staff 2 (Wellness Director) confirmed the above medications lacked reasons for use. The need to ensure all medications on the MAR included the reason for use was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN) on 09/11/24 at 1:30 pm. They acknowledged the findings, and no further information was provided. 2. Resident 2 was admitted to the facility on 08/02/2024 with diagnoses including bipolar disorder. The resident's current prescriber orders and 08/01/24 through 09/09/24 MARs were reviewed and the following medications lacked reasons for use: *Exemestane; *Furosemide; *Labetalol; *Lamotrigine; *Miralax; *Senna; *Fluticasone; *Preservision Areds; *Aspirin; *Sevelamer Carbonate; *Tramadol; *Lamotrigine; and *Lidoc/Prilocaine. In an 09/11/24 interview with Staff 2 (Wellness Director), she confirmed the MARs lacked reasons for use for the medications. The need to ensure MARs were accurate, including reasons for use was discussed with Staff 1 (ED) and Staff 2 on 09/11/24. They acknowledged the findings.

• Community discovered that the 'reason for use' was missing from the printed MAR due to a system setting. • The setting for 'reason for use' population has now been set to default. • An initial audit will be performed to ensure all 'reasons for use' are populated in the system. • Quarterly audits will follow to verify that 'reasons for use' are recorded for each resident. • The Wellness Director and Resident Care Coordinator will be responsible for completing and monitoring this correction.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 2 of 2 sampled residents (#s 1 and 3) who used a supportive device with restraining qualities. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 07/2024 with diagnoses including cerebrovascular accident and impaired cognition. Observations of the resident and interviews with staff indicated the resident had a quarter-length side rail on both sides of his/her bed. On 09/10/24, the side rails were observed to be in the up position, in good repair, and flush with the mattress. The side rails in the up position were identified to be devices with restraining qualities. The resident's service plan, dated 08/28/24, failed to document other less restrictive alternatives were evaluated prior to the use of the device and to instruct caregivers on the correct use and precautions related to the use of the side rails. Staff reported the resident was primarily wheelchair bound and admitted to the facility with the hospital bed and side rails. On 09/10/24 at 4:20 pm, Staff 3 (RN) confirmed an assessment of the side rail was not completed prior to survey entry. The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 on 09/11/24. They acknowledged the findings, and no further information was provided. 2. Resident 3 was admitted to the facility in 07/2021 with diagnoses including Guillain-Barre syndrome and chronic fatigue. On 09/11/24 at 11:52 am, Resident 3 was observed transferring to his/her hospital bed using a left side quarter-length siderail in the up position, which was identified as a device with restraining qualities. Review of Resident 3's record indicated there was no documented evidence of: * Instruction to caregivers on the correct use and precautions related to use of the device; and * Documentation of the use of the supportive device in the resident’s service plan. The need to ensure documentation of the use of the supportive device with restraining qualities was included in Resident 3’s service plan and caregivers were instructed on the correct use and precautions related to the use of the supportive device was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 09/11/24. They acknowledged the findings.

• Resident 1 and 2: Growth and wellness plans have been updated to include instructions for staff on assistive devices with restraining qualities. • Community will conduct an audit to ensure all residents' assistive devices are documented in their growth and wellness plans. • Separate evaluations for assistive devices will be included, detailing less restrictive alternatives and staff instructions. • An in-service will be provided for staff during the 10/30 All Staff meeting, focusing on currently used assistive devices, with a sign-in for attendance. • The community will follow up with any wellness staff who miss the meeting to ensure they receive the necessary training and sign off on it. • Assistive device assessments are completed alongside 90-day growth and wellness plans. • The Community RN and Wellness Director will be responsible for the completion of assessments and ensuring instructional verbiage is included in care plans.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES.(a) Prior to beginning their job responsibilities, all employees must complete an orientation that includes training regarding:(A) Residents' rights and the values of community-based care.(B) Abuse and reporting requirements.(C) Standard precautions for infection control.(D) Fire safety and emergency procedures.(b) If the staff member's duties include preparing food, they must have a food handler's certificate.(c) All staff must receive a written description of their job responsibilities.(d) PRE-SERVICE INFECTIOUS DISEASE PREVENTION TRAINING. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-monthperiod prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:(A) Transmission of communicable disease and infections, including:(i) Policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Respiratory hygiene and coughing etiquette.(B) Standard precautions.(C) Hand hygiene.(D) Use of personal protective equipment.(E) Cleaning of physical environment, including, but not limited to:(i) Disinfecting high-touch surfaces and equipment.(ii) Handling, storing, processing and transporting linens to prevent the spread of infection.(F) Isolating and cohorting of residents during a disease outbreak.(G) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (H) Facilities will be required t have all staff trained, as described in this rule, by July 1, 2022.(e) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.(A) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.(B) Online training will be made available by the Department by January 1, 2022.(C) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.(D) The Department will review training from facilities or other entities with the goal of making training available to facilities by January 1, 2022.(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete theDepartment-approved HCBS training, as provided below:(A) Effective March 31, 2024, all staff must have completed the required training.(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning jobresponsibilities.(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.(a) Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.(b) Pre-service dementia care training requirements for:(A) 2018 - Direct care staff hired on or before December 31, 2018 shall complete pre-service dementia care training outlined in OAR 411-054-0070 by December 31, 2018, regardless of when they first provide direct care to residents.(B) 2019 and beyond - Direct care staff hired on or after January 1, 2019 shall complete required pre-service dementia training prior to providing direct care to residents.(c) Documentation of dementia training:(A) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.(B) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.(d) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility ' s pre-service dementia training.(e) A certificate of completion must be made available to the Department upon request.(f) Pre-service dementia care training must include the following subject areas:(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.(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 the safety of residents with dementia, including, but not limited to, how to:(i) Identify and address pain.(ii) Provide food and fluids.(iii) Prevent wandering and elopement.(iv) Use a person-centered approach.(g) Pre-service orientation to resident:(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident's service plan.(B) Staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly-hired direct care staff (#s 6 and 14) completed all required pre-service orientation prior to beginning their job responsibilities. Findings include, but are not limited to: Training records were reviewed with Staff 4 (Business Office Manager) on 09/11/24. Staff 6 (MT), hired 06/12/24, and Staff 14 (CG), hired 03/08/24, lacked documented evidence of completing fire safety and emergency procedures orientation prior to beginning job responsibilities. The need to ensure newly-hired direct care staff completed all required pre-service orientation prior to beginning their job responsibilities was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director) on 09/11/24. They acknowledged the findings.

Staff files will be audited for documentation of fire and life safety training. • Group training sessions are scheduled for 10/2 and 10/30 during all staff meetings. • The Maintenance Director will follow up on any outstanding trainings and document completion. • A checklist will be implemented for each staff member to ensure pre-service requirements are met before they assume full duties. • The Business Office Manager will ensure all non-wellness staff complete required training. • The Resident Care Coordinator will ensure all wellness staff complete required training. • The Administrator and Wellness Director will review records quarterly to ensure compliance.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) 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. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

OAR 411-054-0070 (2-5)(5-8) Annual Training and Other Requirements (2) An administrator of a facility and the employees of the facility, as specified by the Department of Human Services by rule, must receive training in recognizing disease outbreaks and infection control at the time of hiring, unless the administrator or the employee has received the training at another facility within the 24-month period prior to the time of hiring, and annually as part of, and not in addition to, the administrator or employee's continuing education requirements.(3) The department, in consultation with the Oregon Health Authority, shall prescribe by rule the requirements for the training, which must include at least the following: (a) How to properly prevent and contain disease outbreaks based on the current best evidence in the field of infection and disease outbreak identification, prevention and control;And (b) The responsibility of staff members to report disease outbreaks under ORS 433.004.(4) The training may be provided in person, in writing, by webinar or by other electronic means. The department shall make online trainings available.(5)(a) A facility must establish and maintain infection prevention and control protocols designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases.(5) ANNUAL INSERVICE FOR ALL STAFF. Annual infectious disease training requires the following:(a) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.(b) Annual in-service training must be documented in the employee record.(c) These annual training requirements will be required as of July 1, 2023.(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Annual in-service training hours are based on the anniversary date of hire.(b) Requirements for annual in-service dementia training:(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee ' s assessed competency.(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term direct care staff (#s 7, 8, and 12) completed 12 hours of annual in-service training which included at least 6 hours of dementia care training, and 2 of 2 long-term non-direct care staff (#s 5 and 18) completed annual infectious disease training. Findings include, but are not limited to: Review of the facility's training records with Staff 4 (Business Office Manager) on 09/11/24 revealed the following: * Staff 7 (MT), anniversary date of hire 04/14/23, Staff 8 (MT), anniversary date of hire 04/20/23, and Staff 12 (CG), anniversary date of hire 12/27/22, failed to have documented evidence of completing 12 hours of required in-service training, including at least six hours of training on dementia care annually based on date of hire; and * Staff 5 (Maintenance Director), hired 07/08/22, and Staff 18 (Server), hired 08/01/23, failed to have documented evidence of completing infectious disease prevention training annually. The need to ensure long-term staff completed and documented the required annual in-service training, which included dementia care and infectious disease prevention, was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director) on 09/11/24. They acknowledged the findings.

• Direct care and non-direct care staff audited by Survey will complete training by the compliance date. • The remainder of staff files will be audited to track completion of required annual trainings. • The Business Office Manager will audit Pre-Service Infectious Control training in correlation with staff anniversary dates to ensure annual completion. • A schedule for monthly trainings, as required by staff to maintain compliance, has been created utilizing oregoncarepartners.com. • The Business Office Manager will be responsible for tracking training for non-direct care staff. • The Resident Care Coordinator will be responsible for tracking training for direct care staff. • The Administrator and Wellness Director will review staff records quarterly to ensure compliance.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and 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. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 09/11/24 at 11:54 am. During an interview on 09/11/24 at 12:00 pm, Staff 5 (Maintenance Director) confirmed there was no written record of the training sessions and residents attending for annual fire and life safety instruction. The need to re-instruct residents on fire and life safety training per the OFC requirements was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (RN) on 09/11/24. They acknowledged the findings, and no additional information was provided.

• Mandatory training for residents is scheduled during the week of October 21st to review all fire and life safety protocols. • A sign-in sheet will be provided for attendance. • Training documents outlining procedures will be distributed. • The Maintenance Director and Administrator will conduct the meeting. • The Maintenance Director will follow up with residents who missed the meeting within two weeks of meeting to review information and document that resident has been re-educated.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and 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. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: Observations of the facility interior were made throughout the survey between 09/09/24 and 09/11/24. The following was noted in need of cleaning or repair: *First and second floor elevator shaft doors, exit door near second floor restrooms, doors and door jambs to rooms 102, 106, 110, 201, 204, 207, 209, 214, and 219 had brown and black scuffs, chipped paint and were damaged on the surfaces; and *Elevator thresholds and wall vents throughout the first and second floors had brown and black debris on the surface. The surfaces in need of cleaning and repair were toured with Staff 8 (Maintenance Director) and discussed with Staff 1 (ED) on 09/11/24. They acknowledged the findings.

Elevator and stairwell doors will be cleaned, painted, and receive necessary touch-ups. • Apartment doors and doorframes will be painted and receive required touch-ups. • Vents and elevator thresholds will be cleaned monthly by maintenance and housekeeping staff. • Apartment doors will be checked monthly for repairs. • The Maintenance Director is responsible for overseeing these corrections. • The Administrator will conduct spot checks monthly.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair.

Based on observation, interview, and record review, it was determined the facility failed to ensure food was prepared, and 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 facility kitchen, food storage areas, food preparation, and food service on 03/20/24 revealed splatters, spills, drips, and debris noted on:   - Hand washing sink, walls, and equipment; - Can opener sleeve and casing; - Stand mixer; - Blender; - Reach in refrigerator; - Exterior sides and knobs of the gas range and oven; - Walls throughout the kitchen; - Flooring and cove base throughout the kitchen; - Floor drains; - Doors, flooring, and shelving of walk-in refrigerator and freezer; - Dry storage area flooring, shelving, and food containers; - Dishes and cookware stored on open shelving and racks; - Open stainless steel shelving and metal rack shelving throughout the kitchen; - Bakery racks;   - Underneath shelving and equipment throughout kitchen; and - Dishwashing area including flooring, walls, caulking, and equipment. * Scoops were left in bulk bins of food; * Multiple boxes were stored directly on the floor in the walk-in refrigerator, walk in freezer freezer, and dry food storage area. * Raw ground meat was stored on a box of raw vegetables. * There were undated and unlabeled foods in all refrigerators. * Prepared foods were dated as much as two month old. * Packaged foods were not dated when opened. * Dented can of beans in the dry food storage. * Dish washing racks were stored on the floor. * The steam table cutting board was stained and deeply scored. * Staff were using a Quaternary solution for sanitizing towels. There was no evidence of testing the solution to ensure it was between 150 and 200 parts per million. Staff 1 (Administrator), Staff 2 (Dining Services Director), and the surveyor toured the kitchen. The areas in need of cleaning and food storage issues were reviewed. The staff acknowledged the findings.

In response to the deficiences refered ot under C240 we have scheduled a once a month deep clean to help with sanitation issues. First will take place on 4/13/24. All the major areas of non-compliance will be reviewed and corrected by Dining Service Director. Each of these areas have a daily, weekly, and monthly check off sheets that will be checked by head cook on shift followed by DSD. All areas have been assigned to the employees who work these individual areas of the kitchen. Walk-in has dedicated shelves for each section of the kitchen - Compass Cook, Salad Bar, and Lead Cook. Waitstaff is responsible for the reach in fridge and mini fridge on the line. The freeze has an added cart to give room for any over flow of product to keep product off floor. A daily checklist is posted along with instructions on how to properly measure the sanitation chemicals to keep in compliance. Cooks will be responsible for checking and completely the checklist daily, they are to report to the DSD with any problems. Facility maintenance is in the process of completing repairs to hand washing sink and requesting quotes for dish pit back splash. DSD will be conducting monthly audits of the kitchen and holding inservices with kitchen team to enforce consistent compliance. Administrator to to unscheduled checks to confirm kitchen is staying in compliance.

The findings of the kitchen inspection, conducted 03/20/24, 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.

The findings of the revisit to the kitchen inspection of 03/20/24, conducted 05/24/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure food was prepared, and 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 facility kitchen, food storage areas, food preparation, and food service on 01/17/23 revealed splatters, spills, drips, and debris noted on:   - Can opener blade and casing; - Stand mixer; - Food Processor; - Reach in refrigerator; - Spice self; - Exterior sides and interior of the gas range and oven; - Walls throughout the kitchen; - Flooring throughout the kitchen; - Floor drains; - Doors, flooring, fans, and shelving of walk-in refrigerator and freezer; - Dry storage area flooring, shelving, and food containers; - Vents in cookware storage area; - Dishes and cookware stored on open shelving and racks; - Open stainless steel shelving and metal rack shelving; - Bakery racks; - Knives on the magnetic rack; - Carts; - Underneath shelving and equipment throughout kitchen; - Triple pot sink area; and - Dishwashing area including flooring, walls, caulking, and equipment. * A scoop was left with the handle in the rice. * Multiple boxes were stored directly on the floor in the walk-in freezer. * There were undated and unlabeled foods in all refrigerators. A utensil was left in an unlabeled, undated pan of food. * The low temperature dishwasher was not reaching 120 degrees Fahrenheit and the chemical sanitizer was not reaching the required level.  Staff began using the triple pot sink to wash and sanitize dishes. * Dish washing racks were stored on the floor. Visible debris was noted on the clean side of the dish machine. * There was broken cove base tile with an accumulation of black matter in the dishwashing area. * Staff were using a Quaternary solution for sanitizing towels. There was no evidence of testing the solution to ensure it was between 150 and 200 parts per million. * Staff were observed to not change gloves between tasks while handling ready to eat foods. * Staff did not wash hands upon entry to the kitchen. Staff 1 (Executive Director) and the surveyor toured the kitchen. The areas in need of cleaning and repair were reviewed with Staff 1. He acknowledged the findings.

Plan of Correction: C240 In response to the deficiencies, we hired a professional cleaning service to address the kitchen cleanliness and sanitation on 1/29/23. All of the individual areas identified by the DHS inspector as areas of noncompliance were addressed and reviewed by the Dining Services Director and Administrator. Following the deep clean the following plan was set into place as of 2/1/2023. 1. Dining Director has completed on the job training with all cook's kitchen regarding the immediate expectations of cleanliness, personal protective equipment, hand washing and sanitation of the kitchen. 2. A daily check list was implemented and briefed at every shift to monitor and measure consistent sanitation compliance. 3. A daily cleaning checklist with 1 daily deep clean item that will be completed by the kitchen staff daily and signed off by the supervising cook daily. 4. Quaternary Solution log established and strips in place to be checked every 2 hours and reviewed daily by the supervising cook. 5. Ecolab was in the community to service the Dishwasher on 1/17/2023, chemicals changed out, machine operational and at proper temperature. 6. Facility Maintenance in the process of completing repairs to the appropriate kitchen floor tiles addressed in the inspectors notes. 7. All required items are stored, dated and temperatures appropriately.   8. The Dining Services Director will complete checklist at least 1x weekly to ensure that cooks are completing task outlined. 9. The Dining Services Director will monitor issues that require vendor maintenance and complete monthly sanitation audits to enforce consistent compliance. 10. Community Administrator will conduct random audits of the kitchen for cleanliness, sanitation to focus on areas of high risk and concern from this most recent deficiency.

The findings of the kitchen inspection, conducted 01/17/23, 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 01/17/23, conducted 05/04/23, 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.