Alderwood ALF

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 OAR 333-150-000. Findings include, but are not limited to: On 05/20/26, between 8:00 am and 10:45 am, the kitchen was observed, and the following was identified: 1. Areas in need of cleaning: * Refrigerators/freezers – food debris on doors/handles, black/white matter throughout shelving/fan; * Frying pans and food thermometer – stored away with food debris; * Ovens, grill, stovetop, hood vents, shelving throughout kitchen, can opener, ceiling vents, wall air conditioner, garbage cans, knife rack, bulk bins, floor, roller dollies, microwave, warming drawers – grease/food/dust build-up; and * Freezer – ice build-up. 2. Areas in need of repair/maintenance: * Two sink faucets at three sink – leaking; and * Hand sink faucet – corrosion. 3. Sanitation/Handwashing/Glove Use: *Appliance handles and doors – food debris; * Leftovers in refrigerator were cooled in deep containers; staff were not monitoring time/temperature. Staff discarded the food. * Ice machine – black/white matter inside and dusty vent on exterior. Staff discarded ice and initiated cleaning. * Refrigerator – multiple cooked and uncooked food items undated, unsealed, and/or expired. The areas of concern were observed and/or discussed with Staff 1 (Director of Dining Services) and Staff 2 (Executive Director) at approximately 10:45 am on 05/20/26. Staff acknowledged the findings.

C240 Staff have been re-educated on the following topics and processes: C240 1. Areas in need of cleaning Refrigerators/freezers doors/handles/shelving/fan have been cleaned and sanitized Frying pans and food thermometers have been cleaned and sanitized Ovens, grill, stovetop, hood vents, shelving throughout kitchen, can opener, ceiling vents, wall air conditioner, garbage cans, knife rack, bulk bins, floor, roller dollies, microwave, warming drawers have been cleaned and sanitized Freezer - ice build up has been thawed and will be monitored by staff during weekly cleaning Staff will be inserviced on systemic completion of daily and weekly checklist implementation. Multiple cleaning lists were consolidated to establish clear cleaning protocol. C240 2. Areas in need of repair/maintenance Two sink faucets at three sink has been repaired and is not leaking Hand sink faucet has been replaced with new faucet with eye wash station attached C240 3. Sanitation/Handwashing/Glove Use Appliance handles and doors - food debris Staff have been re-educated to remove gloves when opening appliance handles and doors. Appliance handles and doors are cleaned and sanitized after each meal service. Staff has been informed on proper cooling of food and stoarage in refrigerator. Leftovers are cooled in 2 inch shallow containers with staff monitoring temperature before storing in refrigerator. Staff will monitor cooling time/temperatures. Ice machine - Staff have been inserviced on proper thorough cleaning inside and outside of ice machine. Staff have been inserviced on systemic completion of weekly cleaning checklist. Refrigerator - Staff have been inserviced on dating cooked and uncooked food, properly sealing food items and discarding expired food items. Audits will be conducted weekly for compliance for one month, then monthly for compliance by Dietary Manager. The Administrator will be responsible for monitoring completion and on going compliance.

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 OAR 333-150-000. Findings include, but are not limited to: On 05/20/26, between 11:00 am and 2:00 pm, the facility kitchen was observed, and the following was identified: 1. Areas in need of cleaning: * Refrigerators and freezer – food debris on floors, handles, doors, and shelving; * Refrigerator – black and white matter on fan and shelving; * Counters, flooring, shelving, walls throughout the kitchen - food and/or dust debris; * Oven, stovetop, flat grill, deep fryer, warming drawer, plate lowerator – debris buildup on and around appliances; * Garbage cans – outside splattered with food debris; * Multiple floor drains and top of grease trap – garbage and food debris buildup; * Bulk bins – food debris on lids; and * Ice machine – black and white matter inside. 2. Areas in need of repair/maintenance: * Dish machine – missing data plate; and 3. Sanitation/Cross Contamination/Handwashing/Glove Use: * Sanitation bucket – not at required PH. At approximately 12:30 pm, surveyor observed kitchen staff touching deli sandwich food items and appliance handles without changing gloves or handwashing. Surveyor found soiled dish towel on the deli cutting board. Staff 1 (Dining Services Director) made corrections. At approximately 12:15 pm, surveyor observed food particles from the deli cooler that had fallen into the sandwich food item containers. Cook cleaned the cooler and discarded the contaminated food. At approximately 12:30 pm, surveyor observed white and black matter inside the ice machine. Staff 1 discarded the ice and initiated cleaning. 4. Food Storage: * Refrigerator – several food items without sealed containers; and * Refrigerator - raw and cooked meat without dates. The areas of concern were observed and/or discussed with Staff 1 (Dining Services Director) and Staff 2 (ED) at approximately 2:00 pm on 05/20/26. Staff acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

The findings of the on-site investigation, conducted 07/12/24 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 and Division 57 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:   Observations of the kitchen on 02/21/24 showed the following areas were in need of cleaning or repair. a. Food spills, splatters, debris, dust, white fuzzy substance, black substance, webs and/or dirt were observed on, inside, underneath and/or dangling from the following areas:   * Floors throughout the kitchen and dry storage areas, under all equipment, appliances, and counters; * Floor drains; * Fire extinguisher; * Shelving units throughout the kitchen, refrigerator and freezer units; * Clean dish/pan storage shelves; * Both ovens; * Top of the water heater, walls/floors in linen storage, and walls in janitor closet; * Walls and ceiling throughout the kitchen; * Ceiling vents, stove hood and vents, and suppression spigots in front of the hood vents; * Air conditioning units and small fans; * On top of the stand mixer; and * Fans in the walk in refrigerator. b. Additional observations showed the following: * Food items stored directly on the floor and other food items on the floor underneath bread shelf and in dry storage; * Thick tape was wrapped around the hinge, holding it in place for the glass doors of the walk in refrigerator; * Spray foam along pipe in the walk-in freezer above a large ball of ice was chipped and pieces coming off; * Three cutting boards were significantly worn and had knife damage; * Stand up freezer had a large bulging section of the door along with heavy amounts of frost throughout the freezer; * Black plastic cover on the top of the stand mixer had a large crack on the right side with loose plastic; * Caulking under the spice shelf was both discolored in sections and missing in others; * Chipped, dinged cupboards and shelving throughout the kitchen; * Multiple areas of the floor that was dinged, chipped or had missing pieces. Areas of flooring underneath and around equipment edges and dips and dings to the tiles; * Two plastic/rubber scraping spatulas were dinged with chunks missing from the scraper edge. Two small frying pans with significant oxidation and discoloration as well as one large frying pan; * Three broken dish baskets were noted with missing plastic pieces, as well as significant discoloration and dark accumulation; * Broken floor tile near the toast area; * No test strips could be located; * One of two handwashing sinks did not have hot water. The water was left running approximately 3.5 to 4.5 minutes. The water remained luke warm. Staff 2 (Kitchen Manager) indicated the sink was an ongoing problem but the other ones in the kitchen had hot water without issue; * Cupboards in dining room noted with significant spills and debris in the interior; * No written policy for sick kitchen staff was in place; and * The dish machine was identified as a high temperature machine with chemical boosters by Staff 2. The temperature dial would not rise with the temperature of the machine when in use. The needle on the gauge hovered between 120 and 130 degrees throughout the wash and rinse cycles. The dish machine had no data plate. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Kitchen Manager) on 02/21/24. Staff 1 and Staff 2 stopped use of the dish machine. Staff 2 indicated dishes would be washed and sanitized in the three compartment sink while waiting on repair of the unit.  The staff acknowledged the findings.

C240 1.  Alderwood will maintain a clean and sanitary kitchen according to the food sanitation rules. a.  Alderwood has conducted a deep clean in the kitchen including flooring, floor drains, fire extinguisher, shelving in refridgerator and freezer units, dishpan storage shelves, ovens, water heater, walls, ceiling, vents, stove hood, suppression spigots, air conditioning units, small fans, stand mixer and fans in walk in refridgerator.   b.  The following items have been replaced; dish baskets, cutting boards, spatulas, frying pans and cover on top of stand mixer.   Food items have been properly stored above floor level. Walk in refridgerator hinge has been repaired. Spray foam has been re-applied to walk in freezer. Seals have been replaced on both walk in freezer and refridgerator units. Discolored and missing caulking has been repaired. Hand washing sink shut off valves and water lines have been replaced and is now producing hot water. Cupboards/shelving in kitchen and dining room have been repaired and cleaned. The dish machine is a low temperature machine that uses chemicals.  Ecolab confirmed the dish machine status and will provide a data plate. The temperature gauge has been replaced.  The temperature gauge  needle is reading 145 degrees.  Dish machine test strips have arrived and kitchen staff are monitoring during dish cycles. Employee sick policy has been put in place, signed by staff and all kitchen staff have been inserviced on policy. Flooring contractor has been called to repair chipped, broken and dinged tiles and missing grout areas. 2.  A routine cleaning schedule and checklist has been implemented.  Needed repairs will be noted weekly by staff doing the cleaning and reported to Dietary Manager. 3.  Cleaning audits will be conducted weekly by Dietary Manager and monthly by Administrator.  Dietary Manager and Administrator will meet monthly and discuss repairs and replacement needs. 4. All items will be monitored by Dietary Manager and overseen by Administrator.

The findings of the kitchen inspection, conducted 02/21/24, 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 re-visit to the kitchen inspection of 02/21/24, conducted 06/03/24 through 06/05/24, 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, interview and record review, it was determined the facility failed to ensure resident evaluations were reflective of the resident's health status, current needs or addressed all required components for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose new move-in or quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 2016 with diagnoses which included diabetes. Observations, resident and staff interviews, and review of the record was conducted during the survey. The most recent evaluation, dated 05/18/23, was not reflective of the resident's health status, current needs or did not address the required components in the following areas: * Visits to health practitioner(s), ER, hospital or NF in the past year; * History of dehydration or unexpected weight loss or gain; * Recent losses; * Unsuccessful prior placements; * Elopement risk or history; * Smoking, ability to smoke safely; * Alcohol and drug use; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. On 06/14/23, the need to ensure Resident 2's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the findings. 2. Resident 3 moved into the facility in 01/2023 and had diagnoses which included dementia. Observations, resident and staff interviews, and review of the record was conducted during the survey. The most recent evaluation, dated 05/18/23, was not reflective of the resident's health status, current needs or did not address the required components in the following areas: * Customary routines: sleeping; * Visits to health practitioner(s), ER, hospital or NF in the past year; * Mental issues including: Presence of depression, thought disorders or mood problems; * Pain: Pharmaceutical and non-pharmaceutical intervention, including how the resident expressed pain or discomfort; * Fall risk history; * Complex medication regimen; * Unsuccessful prior placements; * Elopement risk or history; * Smoking, ability to smoke safely; * Alcohol and drug use; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. On 06/14/23, the need to ensure Resident 3's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the findings. 3. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and emphysema. Review of the most recent evaluation dated 06/05/23 revealed the evaluation was not reflective of the resident's health status, current needs, or did not address the required components in the following areas: * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences and traditions; * Visits to health practitioner(s), ER, hospital or NF in the past year; * Mental Health issues including: presence of depression, thought disorders or behavioral or mood problems; history of treatment; and effective non-drug interventions; * Personality: including how the person copes with change or challenging situations; and * Ability to use call system; * Recent losses; * Unsuccessful prior placements; * Elopement risk or history; * Smoking, ability to smoke safely; * Alcohol and drug use; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. The need to ensure Resident 1's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. The findings were acknowledged. 4. Resident 4 was admitted to the facility in 04/2023 with diagnoses including Type 2 diabetes and Parkinson's Disease. Review of the initial evaluation dated 04/21/23 revealed the following elements were missing: * Spiritual, cultural preferences and traditions; * Personality: including how the person copes with change or challenging situations; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. The need to ensure the initial evaluation included all of the required elements was discussed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. The findings were acknowledged.

1.  All required components of the evaluation tool have been implemented and are in use for all new resident move-ins as well as quarterly evaluations. Residents 1,2,3 & 4 will be evaluated using the new tool and all required components have been addressed. 2.  The evaluation tool has been implemented with all new resident move-ins and incorporated in quarterly service plans on our routine schedule. 3.  All evaluations will be reviewed for completion during the routine move in process, significant change of condition or the routine service plan schedule. 4.  HCC and Administrator will be responsible for monitoring process as outlined above.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3 and 4's current service plans were reviewed during the survey. On 06/14/23 at 11:00 am, Staff 1 (Administrator) confirmed the facility lacked documented evidence of a Service Planning Team to participate and review the individual service plan. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 and Staff 2 (Owner) on 06/14/23. They acknowledged the findings.

1.  A Service Planning Team has been put in place for Residents 1,2,3, and 4 along with all residents in the community, which includes documented evidence of team member participants. 2.  All Service Plan Team members will review service plan and document revisions based on resident evaluation prior to resident scheduled care conference. Service Plan Team will sign service plan discussed with resident, family and participants attending care conference. 3.  The system will be evaluated weekly as the Service Plan Team works throught the care planning calendar. 4.  Health Care Coordinator and Administrator will audit Service Plan book monthly for evidence of Service Plan Team participation.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to an order, for 1 of 1 sampled resident (#1) who had documented medication refusals. Findings include, but are not limited to: Resident 1 moved into the facility in 2021 and had diagnoses including chronic obstructive pulmonary disease and emphysema. Resident 1's MARs were reviewed for the time period of 05/01/23 through 06/12/23. Staff documented Resident 1 refused the following for the month of 05/2023: * Diltiazem (for blood pressure) on 22 occasions; * Escitalopram (for depression) on 13 occasions; * Furosemide (for pulmonary edema) on 13 occasions; * Hydralazine (for blood pressure) on 22 occasions; * Levothyroxine (for hypothyroidism) on 13 occasions; * Omeprazole (for stomach care) on 13 occasions; * Docusate (for constipation) on six occasions; * Ferrous sulfate (for iron deficiency) on 14 occasions; * Boost pudding (for muscle weakness) on 11 occasions; * Eliquis (for blood clot prevention) on 23 occasions; and * Levetiracetam (for seizures) on 21 occasions. Staff documented Resident 1 refused the following for the time period of 06/01/23 through 06/12/23: * Diltiazem (for blood pressure) on three occasions; * Hydralazine (for blood pressure) on three occasions; * Eliquis (for blood clot prevention) on one occasion; and * Levetiracetam (for seizures) on three occasions. In an interview on 06/13/23, Staff 4 (RCC) reviewed the record and acknowledged there was no documented evidence the facility had notified the physician/practitioner of the refusals. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. The findings were acknowledged.

1. Medications for Resident 1 have been reviewed by RN, Consultant Pharmacist and Consulting RN.  Physician has been notified of history and pattern of refusals and recommendations have been made for prescribing PRN medications when appropriate.   2.  All Med Techs have been in-serviced on the need to notify physicians of refusals per order as outlined in the Service Plan.  Refusals are to be noted appropriately in Resident's Progress Notes and physician communication will be tracked through pending notification faxes. 3.  Missed Medication notes will be reviewed per electronic health record (PCC) to track medication refusals at least 3-5 times a week. 4. Process will be monitored and confirmed by RN.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN medications for behaviors. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2016 with diagnoses including depression and anxiety. Resident 2 had a physician's order for Clonazepam 0.5 mg one twice daily as needed for anxiety. Review of MARs and progress notes, from 05/01/23 through 06/12/23, revealed staff administered PRN Clonazepam on 57 occasions. There was no documented evidence staff had attempted non-drug interventions with ineffective results prior to administering the psychotropic medication. The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 on 06/14/23. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and emphysema. Resident 1 had a physician's order for Lorazepam 0.5 mg tablet by mouth four times daily as needed for agitation, anxiety or shortness of breath. Review of MARs from 05/01/23 - 06/12/23 revealed staff administered PRN Lorazepam on one occasion. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the psychotropic medication. In an interview on 06/13/23 at 1:00 pm, Staff 4 (RCC) reviewed the MAR and progress notes. She acknowledged staff did not document non-drug interventions attempted prior to administering the PRN. The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. They acknowledged the findings.

1. Non pharmacological interventions to employ prior to use of psychotropic medications to treat Resident 1 and Resident 2 have been detailed in their respective service plans and MAR's (medication administration record). 2. Caregivers and Med Techs have been in-serviced on the need to employ non pharmacological interventions in all scenarios prior to use of psychotrophic interventions.  Med Techs will document intervention effectiveness as evidenced by observations in progress notes before each Psychotropic Medication administration. 3.  Non pharmacological interventions will be re evaluated quarterly or as needed with service plan review. 4.  Process will be monitored and followed up by RN and Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use, documented other less restrictive alternatives prior to use, provided instruction to caregivers on correct use and precautions, and documented use of the rails in the resident's evaluation and service plan for 1 of 1 sampled resident (# 1) who had side rails.  Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and emphysema. During an interview on 06/13/23 at 12:10 pm, Resident 1's hospital bed was observed to have half-length side rails on the left side of the bed. The side rails were in the up position and securely fastened to the bed. In an interview with Staff 1 (Administrator) on 06/13/23 at 4:30 pm, side rail assessment documentation was requested. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan. The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements was discussed with Staff 1 and Staff 2 (Owner) on 06/14/23. They acknowledged the findings.

1.  A Supportive Device Assessment with potentially restraining qualities has been completed on Resident 1.  Less restrictive alternatives have been discussed with hospice, findings have been documented in health record and service plan has been updated. 2.  A supportive device assessment with restraining qualities audit will be performed for all residents.  Assessments will be completed as necessary and care plans have been updated. 3.  All pending orders will be reviewed by RN and assessments will be performed prior to implementing any orders for restraints.  All staff have been in-serviced on the identification of supportive devices with portentially restraining qualities.  New hire staff have identification of supportive devices in their 30 day training.  Reassessment of each resident with supportive devices with potentially restraining qualities will be reviewed quarterly. 4.  Process will be monitored by RN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure documentation that 4 of 4 sampled newly hired employees (#s 9, 10, 11 and 12) completed pre-service orientation and dementia care training prior to assuming their job duties. Findings include, but are not limited to: Staff training records were reviewed on 06/13/23. The following deficiencies were identified: a. Staff 9 (CG), hired 03/02/23, lacked documented evidence of having completed Infectious Disease Prevention and pre-service dementia training. b. Staff 10 (CG), hired 04/28/23, lacked documented evidence of having completed Infectious Disease Prevention and pre-service dementia training. c. Staff 11 (MT), hired 04/05/23, lacked documented evidence of having completed Infectious Disease Prevention training. d. Staff 12 (Waitstaff) was hired 05/22/23. There was no documented evidence Staff 12 completed the following training requirements: * Fire Safety and emergency procedures; and * Infectious Disease Prevention. The need to ensure staff completed pre-service training was reviewed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/13/23 at 3:30 pm. They acknowledged the findings.

1.  Staff 9, 10 and 11 will complete required preservice Dementia Care and Infectious Disease Prevention training.  Staff 12 will complete Fire Safety and Emergency procedure in-person in-service and Infectious Disease Prevention training. 2.  An audit of all current staff has been conducted and non-compliant staff have been scheduled to complete required training 3.  A new employee pre-employment orientation and training process has been developed and implemented.  As part of that program, staff will complete required pre-service training prior to being placed on the schedule for regular duties.  Compliance will be tracked in "Employees at a Glance". 4.  "Employees at a Glance" will be reviewed monthly at routine staffing meeting between The Staffing Coordinator and the Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 caregiving staff (#s 10 and 11) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 06/13/23. There was no documented evidence Staff 10 (CG) and 11 (MT), hired 04/28/23 and 04/05/23 respectively, had demonstrated competency in all required areas and within 30 days of hire including: * Role of service plans in providing individualized care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation, and reporting; and * General food safety, serving and sanitation. Additionally, there was no documented evidence Staff 10 had completed First Aid certification and abdominal thrust training within 30 days of hire. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/13/23. They acknowledged the findings.

1.  Competency evaluations including all required components will be completed for Staff 10 and 11.  Completed competency evaluations will be placed in their employee files. 2.  An audit of all direct care staff has been completed and non-compliant staff will demonstrate competencies for all required components.  Updated competency evaluations will be included in their employee files. 3.  A new employee pre-employment orientation and training process has been developed and implemented.  At the completion of that program, staff will complete competency evaluations.  Compliance will be tracked in "Employees at a Glance". 4.  "Employees at a Glance: will be reviewed monthly at routine staffing meeting between the Staffing Coordinator and the Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to include required components on fire drill records. Findings include, but are not limited to: Fire and life safety records, reviewed between 01/2023 through 06/2023, revealed the following: * Fire drill records lacked the following components: - Escape route used; - Problems encountered and comments relating to residents who resisted or failed to participate in the drills; - Evacuation time period needed; - Number of occupants evacuated; and - Evidence alternate routes were used during fire drills. In an interview on 06/13/23 at 2:45 pm, Staff 1 (Administrator) acknowledged fire drill records lacked the required components.

1.  A New Fire Drill tracking form has been implemented that includes all required elements as outlined in OAR 411-054-0090. 2.  The new form has been implemented for all Monthly Fire Drills and has been in use since July 1, 2023 and has been completed by all participating parties. 3.  A Fire Drill schedule has been calendared to include scheduled, unannounced Fire Drills on a monthly basis.  Drills will rotate through all three shifts and evacuations performed on day shift and swing shift drills. 4.  The Fire Drills will be monitored by the Administrator.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training annually. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following deficiencies were identified: * Documentation of annual fire and life safety training provided to residents. The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 (Administrator) on 06/13/23 at 2:45 pm. She acknowledged the findings.

1.  Existing residents will be instructed on Fire and Life Safety procedures including evacuation methods, responsibilities during drills and designated meeting spaces. 2.  All residents will be oriented to Fire and Life Safety procedures upon move-in and will be performed within the first 24 hours. 3.  Annual resident in-servicing will be conducted in July for all residents.  Instruction options will include in-person, one-on-one discussions, group discussions and written instructions. 4.  Resident Orientation will be conducted the the Activity Director and overseen by the Administrator.

Based on observation and interview, it was determined the facility failed to ensure pathways were maintained in good repair and did not have potential hazards. Findings include, but are not limited to: Observations of the outer courtyard surfaces and pathways on 06/12/23 showed the following: * Multiple drop-offs of 2-4 inches along pathway edges of the courtyard. The need to ensure pathways were maintained in good repair and did not have potential hazards was discussed with Staff 1 (Administrator) and Staff 2 (Owner) during a tour of the exterior grounds on 06/13/23 at 11:40 am. The findings were acknowledged.

1.  A landscaping company has been contracted with to blow in bark dust to level drop-offs along the edge of pathways in the courtyard. 2.  All exterior paths will be reinforced to level up drop-offs and potential drop-offs to prevent future issues. 3.  Walk way edges will be monitored through routine walk-abouts and quarterly audits. 4.  The Maintenance Director will be responsible for monitoring walk way edges and the process will be overseen by the Administrator.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 06/12/23. The following was observed: * Lower cabinets in the activity room were scraped/scuffed; * Cabinets in the dining room were scraped/scuffed; * Tables throughout the dining room were scraped on the edges; * Chairs throughout the dining room were scraped/scuffed; * Carpet in front of Room 109 was stained; * Baseboard that surrounded RCC desk area was scuffed; * Spills on the wall by the door to the outside in the hallway of Room 125; * Inside the elevator had boards around the base that were scuffed and gouged; * Multiple doors leading to the exterior had gouged, scuffed door jambs and doors; * A couch in the 2nd floor library was stained; and * A wall outside of Room 233 had gouges. The environment was toured on 06/13/23 at 11:40 am with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the above areas needed to be cleaned and repaired.

1.  Cabinet Doors in the Activity Room and the Dining Room will be sanded and re-stained.  Table edges will be re-stained.  Chairs in the Dining Room are in the process of being recovered and legs will be re-stained.  Stains in the carpet and library couch will be pointed out to cleaning company to address problem areas.  Walls, doors, baseboards have been cleaned and paint will be touched up where necessary. 2.  Staff has been in-serviced on reporting issues to Housekeeping or Maintenance when issues are identified. 3.  A routine preventive Maintenance schedule has been implemented to continously address issues as they arise. 4.  The Maintenance Director and Housekeeping Supervisor will be reponsible for ongoing monitoring and cleaning of building and furnishings.  Administrator will maintain oversight through routine walk throughs and review of Maintenance and Housekeeping logs.

The findings of the Change of Ownership survey conducted 06/12/23 through 06/14/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 06/14/23, conducted 03/26/24 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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 01/18/23 revealed splatters, spills, drips, and debris noted on:   - Stand mixer; - Exterior sides and behind the gas range and oven; - Walls throughout the kitchen; - Flooring throughout the kitchen; - Cookware stored on open shelving and racks; - Open shelving and metal rack shelving; - Bakery racks; - Underneath shelving and equipment throughout kitchen; - Triple pot sink area; and - Dishwashing area including flooring, walls, and equipment. * Raw chicken was left in a bucket of standing water in the sink. * The laminate to the tray line was damaged creating an uncleanable surface. * A scoop was left with the handle in the flour. * Box of food was stored directly on the floor in the walk-in freezer. * There were undated and unlabeled foods in all refrigerators. * The chemical sanitizer for the low temperature dish machine was not monitored to ensure it was reaching the required level. * Dish washing racks were stored on the floor. * 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. * Dietary Staff were observed to not change gloves between tasks during food preparation and service. * Dietary Staff did not wash hands upon entry to the kitchen. * Dietary Staff did not have long hair restrained. Staff 3 (Dietary Manager) and the surveyor toured the kitchen. She acknowledged the findings. The areas in need of cleaning and repair, food storage, sanitation and hand hygiene were reviewed with Staff 1 (Executive Director) and Staff 2 (Facility Owner) on 01/18/23.

Staff have been re-educated on the the following topics and processes: * Proper procedure for ensuring that the foods being served have been properly temped prior to being served to the residents. * Staff have been re-educated on the need to have their hair pulled back and restrained during meal service. * Foods that are being served to the residents will be covered for delivery Thermometers are made available to staff for temping foods prior to serving. Temp logs will be implemented for documentation of temped foods.  Foods being served for room service will be covered prior to leaving the kitchen area. Audits will be conducted weekly for compliance for one month, then monthly for compliance. The Administrator will be responsible for the correction and on going complianc

The findings of the kitchen inspection, conducted 01/18/23, 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 01/18/23, conducted 04/27/23, 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.