Emerald Valley Assisted Living

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

Observation of the facility kitchen was reviewed on 06/09/25from 11:00 am through 1:30 pm and found the following:

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

* Wall in service area
* Baseboards in service area
* Interior of ice machine
* Interior of reach in cooler
* Hot chocolate dispenser
* Light fixture in dry storage

b. Kitchen staff was observed preparing food, serving food and handling clean dishes without effective hair restraint as required.

c. Multiple items in reach in refrigerators were observed not covered/protected from potential contamination when stored.

d. Dish machine was run multiple times and was found not registering the proper chemical parts per million to ensure dishes were effectively sanitized. Upon further investigation Staff 2 (Dining Services Director) found that the chemical bucket drawing sanitizer into machine was not the “right color” and stated staff must have added water to the bucket as the chemicals are stored in their office. A new bucket of sanitizer was obtained, and the dish machine was ran and found at 50 ppm. Staff 2 acknowledged the dish machine was not effectively sanitizing the dishes and was unsure how long it had the incorrect solution strength.

e. The facility was observed to not have a 3 compartment sink and the dish machine was not correctly sanitizing. The facility did not have an exception of the requirement to have a 3 compartment sink with census capacity greater than 17 residents. Interview with Staff 1 (Executive Director) at approximately 1 pm, indicated that the dish machine has needed repair and had just recently been repaired.

f. Cook was observed to handle a water sprayer on the dirty side of the dish machine to rinse off a pan then proceed to the clean area of the dish machine and handle clean dishes with potentially contaminated hands.

g. During lunch tray line service, the cook was observed leave the line multiple times and touch reach in refrigerator handles, grab containers, touch their glasses, touch their clothing, and did not change gloves. The cook was observed to grab RTE (ready to eat) foods with their contaminated gloves. At one point in service, Staff 2 was observed to touch and open a bag of raw chicken. Staff 2 did not thoroughly wash hands after removing gloves.


At 12:45pm, surveyor reviewed identified areas of concern with Staff 2 who acknowledged the areas.
At approximately 1:15 pm, surveyor discussed food code and rule violations observed with Staff 1 who acknowledged areas needing correction.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 04/15/24, 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 first re-visit to the kitchen inspection survey of 04/15/24, conducted 06/07/24, 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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was reviewed on 04/15/24 from 11:10 am through 3:00 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Reach in coolers and freezers;* Industrial can opener and housing;* Tray holding clean dishes;* Range and grill knobs;* Interior of ice machine; and * Metal racks in dry storage with white residue build up.b. The following areas were in need of repair: * Hole in wall above grill/range hood where pipes were.;* Hand washing sink faucet with leak causing water build up on floor;* Threshold to kitchen missing tile and not smooth cleanable surface;* Metal rack in reach in by service area with rust areas;* Metal racks in dry storage with rusted areas; and* Sections of caulking by dish machine cracked/missing or with black debris.c. Large metal pan of gravy observed in reach in cooler. Visible signs of improper cooling noted (heavy condensation on cover, cracks in food product, etc). There was no date or label on product. Staff 2 (Cook/Person in Charge) indicated it was gravy from breakfast that was to be used for lunch. Item was placed on stove top but was never used. Item was discarded after lunch service. Staff 2 validated proper cooling methods include transferring hot items into shallow or smaller containers, cooling some prior to covering completely, and placing in ice bath if needed. S/he acknowledge this was not done with this food product. Staff did not check temperature of that food item to validate time temperature steps for cooling were met. d. Multiple sauté pans and cooking utensils with visible damage and wear needing to be replaced. Pot holders observed with rips and exposed non cleanable surfaces.e. Multiple food items found in reach in coolers or freezers without proper labels and/or dates as required. Items found open or not sealed appropriately to protect from potential contamination. Bulk items were not dated with use by dates when removed from original packaging.f. Multiple food packages were found in dry storage not dated when opened and/or not securely closed to protect from potential contamination. Bulk items were not dated with use by date when removed from original packaging.g. Facility does not have a three compartment sink as required. Staff 2 was able to review steps for proper sanitizing dishes if dish machine was not operational. S/he indicated staff utilized a tub for the third compartment or may utilize another close by sink as the third compartment if needed. h. Multiple dishes and/or disposable delivery service items were not stored covered or inverted as required to protect from potential contamination. i. Multiple kitchen staff observed to not effectively wash/sanitize hands when going from washing/handling dirty dishes to handling clean dishes as required. j. Multiple kitchen staff were observed to not wash tomato when slicing for RTE (ready to eat) items to serve to residents. Staff 2 acknowledged that the tomatoes used were not pre washed and needed to be washed prior to RTE items.k. One kitchen staff was observed to not have facial hair restrained as required. l. Items in cold storage were found past their use by date or past seven days from opened or prepared date. Staff 2 toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 2:30 pm, surveyor reviewed above areas with staff 1 (Administrator), who acknowledged the identified areas in need of correction.
The findings of the first re-visit to the kitchen inspection survey of 04/15/24, conducted 06/07/24, 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.

The findings of the re-licensure survey, conducted 10/30/23 through 11/02/23, 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 OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the re-visit to the re-licensure survey of 11/02/23, conducted 03/13/24 through 03/14/24, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements for 1 of 2 sampled residents (#4) who recently moved into the facility. Findings include, but are not limited to: Resident 4 was admitted to the facility in 10/2023 with diagnoses including depression. Review of his/her initial evaluation, dated 10/02/23, revealed the following required elements were not addressed:* History of treatment for depression;* Effective non-drug interventions for depression;* Decision-making abilities; and* Personality, including how the person copes with change or challenging situations.The need to ensure all required areas were addressed in initial evaluations was discussed with Staff 1 (Operations Director/Acting ED) and Staff 3 (Wellness Director) on 11/02/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2011 with diagnoses including hypertension, Parkinson's Disease, and osteoporosis.Resident 1's most recent service plan was dated 07/04/23. There was no documented evidence the service plan had been reviewed and updated quarterly, as required.In an interview on 10/30/23, Staff 2 (RN Oversight) and Staff 3 (Wellness Director) acknowledged Resident 1's service plan had not been updated quarterly. No further information was provided.
Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, were reviewed quarterly, and/or a copy was provided to the resident's legal representative for 2 of 3 sampled residents (#s 1 and 3). Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 2016 with diagnoses including dementia.a. Review of the resident's clinical record and interviews with the resident and staff revealed the service plan was not reflective of the resident's past history of placing his/her feces in atypical and sometimes concealed areas of his/her apartment. There was no direction to staff about how they should monitor the resident for this behavior or how to respond if the behavior occurred again.b. According to a progress note, the resident's service plan was updated and reviewed on 09/18/23. In an interview with Witness 1 (Family), s/he reported the resident's power of attorney was not involved in that review and had not received a copy of the current service plan.On 11/02/23 the need to ensure service plans were reflective of current status, presented clear directions to staff, and were provided to the resident or the resident's legal representative was discussed with Staff 1 (Operations Director/ Acting ED) and Staff 3 (Wellness Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a service planning team consisting of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or who provided services to the resident was involved in updating the service plan for 1 of 3 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in 2016 with diagnoses including dementia.The resident's current service plan was reviewed. The care plan was not dated; however, there was a progress note stating the service plan had been reviewed and updated on 09/18/23.On 10/31/23 Staff 3 (Wellness Director) reported she was unable to find documentation of a service planning team for the resident's current service plan.In an interview on 11/01/23, Witness 1 (Family) reported neither the resident's legal representative or the family was involved in the 09/18/23 service plan update.The need to include the resident or their representative, and anyone else the resident requested, in updating service plans was discussed with Staff 1 (Operations Director/Acting ED) and Staff 3 (Wellness Director) on 11/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate short-term changes of condition, determine actions or interventions for changes, communicate interventions to staff on all shifts, and monitor changes through resolution for 1 of 3 sampled residents (#3). Findings include, but are not limited to:Resident 3 moved into the facility in 2016 with diagnoses including dementia. Review of the resident's clinical record revealed the following:a. Entries on a "Wellness Notes" form indicated that on two separate occasions (07/25/23 and 08/21/23) Staff 7 (Care Associate) discovered the resident's feces in the bathroom, once in a cup on the counter and once in a drawer.There was no documented evidence these behaviors were evaluated, actions or interventions were determined and communicated with staff, or were monitored through resolution.On 10/31/23, Staff 2 (RN Oversight) reported she was unaware of these behaviors. Staff 3 (Wellness Director) indicated the resident had not demonstrated the behavior prior to 07/25/23 or since 08/21/23.b. A 09/25/23 progress note indicated the resident had "a bump protruding from [his/her] belly near [his/her] belly button."There was no documented evidence the facility evaluated this change of condition, determined actions or interventions, communicated interventions with staff on all shifts, or monitored the change through resolution.On 11/01/23, Staff 3 (Wellness Director) indicated she was not informed by staff of the bump on the resident's belly.The need to evaluate all changes of condition, determine and communicate to staff actions or interventions, and to monitor changes through resolution was discussed with Staff 1 (Operations Director/Acting ED) and Staff 3 (Wellness Director) during the survey. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 6 and 10) completed all required pre-service orientation, and 1 of 2 newly hired direct-care staff (#6) completed all required dementia training prior to beginning their job responsibilities. Findings include, but are not limited to:Staff training records, reviewed on 11/01/23 with Staff 9 (Business Office Manager), identified the following:1. There was no documented evidence Staff 6 (Med Aide) or Staff 10 (Care Associate), hired on 08/22/23 and 09/21/23, respectively, completed the following required pre-service orientation topics:* Fire safety and emergency procedures; and* Written job description.2. There was no documented evidence Staff 6 completed the following pre-service dementia training topics: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;* Strategies for addressing social needs & engaging them in meaningful activities; and* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach. The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 1 (Operations Director/Acting ED) on 11/02/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 10 and 11) demonstrated competency in their job duties within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 11/01/23 with Staff 9 (Business Office Manager).1. Staff 6 (Med Aide) was hired 08/22/23. There was no documented evidence Staff 6 demonstrated competency in their job duties within 30 days of hire in the following areas:* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition; and* Conditions that require assessment, treatment, observation, and reporting.2. Staff 10 (Care Associate) was hired 09/21/23. There was no documented evidence Staff 10 demonstrated competency in their job duties within 30 days of hire in the following areas:* Role of service plans in providing individualized care;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions that require assessment, treatment, observation, and reporting; * General food safety, serving, and sanitation; and* First aid/abdominal thrust.3. Staff 11 (Med Aide/Care Associate) was hired 09/27/23. There was no documented evidence Staff 11 demonstrated competency in their job duties within 30 days of hire in the following areas:* Conditions that require assessment, treatment, observation, and reporting; * General food safety, serving, and sanitation;* First aid/abdominal thrust; and * Other duties as applicable - medication administration. Documentation was provided by Staff 1 (Operations Director/Acting ED) on 11/01/23 that Staff 11 would not be allowed to perform medication administration duties until evidence of competency was obtained.The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 on 11/02/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 12 and 13) completed a minimum of six hours of annual in-service training on dementia care, and 1 of 2 long-term staff (#12) completed a minimum of 12 hours of annual in-service training on topics related to the provision of care for persons in a community-based care (CBC) setting. Findings include, but are not limited to:Staff training records were reviewed on 11/01/23 with Staff 9 (Business Office Manager). 1. There was no documented evidence Staff 12 (Care Associate/Med Tech) completed a total of 12 hours of annual in-service training which included a minimum of six of hours of training related to dementia care.2. There was no documented evidence Staff 13 (Care Associate) completed a minimum of six hours of training related to dementia care.The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Operations Director/Acting ED) on 11/02/23. She acknowledged the findings.

Based on interview and record review, it as determined the facility failed to provide fire and life safety instruction to staff on alternate months, failed to conduct unannounced fire drills on all shifts every other month, and failed to document all required elements of fire drills, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records were reviewed on 10/31/23, and the following was identified:* There was no documented evidence staff were instructed on fire and life safety on alternate months from fire drills;* Fire drill records did not include evidence fire drills were being conducted every other month on all shifts; and* Fire drill records did not include documentation of the escape route used, staff members on duty and participating, and evidence alternate routes were used during drills.The need to follow the OFC requirements for fire drills and fire and life safety instruction for staff was discussed with Staff 1 (Operations Director/Acting ED) on 11/01/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to keep all interior surfaces in good repair, including maintaining cleanable walls in the laundry room. Findings include, but are not limited to:The interior of the building was toured on 10/30/23. The following areas needed repair:* The wall in the laundry room behind washing machines showed cracked, crumbling sheet rock and visible water damage; and * A different wall on the left side of the laundry room showed multiple small holes and marks on drywall, creating an uncleanable surface.On 10/31/23, the laundry room deficiencies were discussed with Staff 1 (Operations Director/ Acting ED) and Staff 5 (Vice President of Operations). They acknowledged the findings.

The findings of the on-site investigation, conducted on 07/26/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a site visit on 07/26/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:In review of the facility's ABST and resident roster on 07/26/23, it was determined there was 32 residents listed on the roster and only 31 residents were entered into the ABST.In an interview on 07/26/23, Staff 1 (Executive Director) stated the current census was 32 residents. S/he also stated they had a new move-in and the ABST was not updated yet.On 07/26/23, findings were reviewed with and acknowledged by Staff 1. The facility failed to fully implement and update an ABST.