Spring Valley Assisted 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 the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 02/24/26 from 10:50 am through 1:45 pm revealed the following; a) Accumulation of, splatters, spills, drips, dust, black matter, food and other debris noted on: * Interior of ice machine; * Industrial can opener and housing; * Removable hood vents; * Reach-in freezer exterior vent; * Stainless steel bottom shelf of back prep table storing clean dishes and cutting boards; * Oven mitts/hot pads; * Interior of small reach-in refrigerator in dining room; b) The following areas/items were found needing repair; * Seal of small-reach in refrigerator in dining room found with cracks/damage and needed repaired/replaced. c) Interior of ice machine found with excessive build-up of black and pink debris/organic matter on the interior of the machine. Staff 2 (Dining Service Director) did not know when the last time the machine had been cleaned/serviced. Staff 2 believed it was the maintenance personnel who was responsible for the cleaning/maintenance. Staff 2 acknowledged the build up was concerning and posed a potential contamination issue of the ice. Staff 2 indicated he would empty the ice and get it cleaned/maintenance as soon as possible. d. Surface sanitation buckets were noted at zero parts per million (PPM) of sanitizer. Staff 2 (Dining Services Director) indicated buckets were to be switched every two hours, and the cook on duty should make the bucket first thing when coming on shift. Cook on duty stated she did not make the bucket and did not know when the bucket was made stating “probably last night.” The bucket water was cold to the touch. Staff 2 made a fresh bucket which tested at the correct PPM. e. Multiple potentially hazardous food items were noted stored without open dates. Multiple items were found past seven days of opened/prepared or past the posted manufacturer’s use-by date. Staff 2 stated those items would be discarded. f. Multiple cutting boards were observed with deep scoring/damage and in need of repair or replacement. Multiple plate cover dome lids were observed melted/damaged yielding non cleanable surfaces and in need of replacement. g. Care staff were observed to enter the kitchen area multiple times, handled kitchen equipment and prepared drinks for meal service, and did not wash their hands. h. Care staff did not have facial hair effectively restrained when in kitchen area and was observed handling clean dishes and preparing drinks for meal service. This care staff also was not wearing his apron correctly so that the apron covered the torso area to create a clean barrier between care giving tasks and meal service activities posing a potential cross contamination issue. i. Non dietary staff were observed to enter and pass through kitchen utilizing it as a short cut, posing potential contamination concerns. Non-essential and unauthorized staff are prohibited from kitchen and meal service areas. j. Cook on duty was observed to potentially contaminate her gloves during meals service by handling meal tickets, marker, drawer handles, and other items, then proceeding to touch ready to eat food items (corn bread, cut up chicken). k. Trash can in kitchen did not have a lid for when not in use. Staff 2 verified there was no lid for that trash can. i. Staff were observed to pour drinks for room tray service and deliver to rooms without placing covers over the drinks, causing potential contamination issue during meal/beverage transport. At 1:15 pm, surveyor reviewed areas with Staff 2 who acknowledged findings. At 1:30 pm the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Administrator). She acknowledged the findings.

A. The ice machine was cleaned and was added to the monthly cleaning schedule. The industrial can opener and housing were cleaned and were added to the daily cleaning schedule, and will be cleaned after every use. The removeable hood vents were cleaned and were added to the weekly cleaning schedule. The reach-in freezer, exterior vents were cleaned and were added to the monthly cleaning schedule. The stainless steel, bottom shelf of the back prep table was cleaned and was added to the daily cleaning schedule, and will be cleaned as needed. New oven mitts/hot pads were ordered. The interior of the small reach-in was cleaned and was added to the daily cleaning schedule, B. For the damaged seal on the small, reach-in fridge, replacement parts were ordered from the manufacturer and will be installed before 4/25/26. C. Ice machine was fulled drained, cleaned, and restocked with ice. D. The water & sanitizing solution in the sanitation buckets will be replaced every 2 hours and monitored on a log one time per shift. E. Appropriate labeling stickers were ordered and are being used to label all food with the date it was opened and a description of what it is. This will be monitored daily. F. New cutting boards ordered and old ones were thrown away. New plate covers were also ordered, G. Formal Hand Washing training was conducted with all staff members, and on-going training will be conducted as needed. H. Formal training was conducted about facial hair restraints and how to wear an apron properly is scheduled for 3/18/26 with all staff members, and on-going training will be conducted as needed. I. Formal training was conducted to explain that staff should enter the kitchen for dining related purposes, not as a pass through or walk through to get to another part of the community. A sign was posted on the entrance door of this area discouraged staff from using it as a pass through. J. Formal training was conducted with all dietary staff about proper use of gloves and handling of raw food without utensils. K. A trash can lid for kitchen trash can was purchased. L. Formal training was conducted about putting lids or coverings on all drinks delivered through room/tray service. 2. Trainings for staff was coducted to educate and reeducate all staff regarding these topics. Additionally, updated logs were put into place to monitor compliance with the regulations. 3. On-going training on these topics will be conducted quarterly and as needed. Logs will be reviewd weekly. 4. Dining Services Director and Executive Director.

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

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 05/13/26, from 12:00 pm through 1:15 pm, revealed the following: a. Interior of ice machine was noted with accumulation of black, grey, and rust colored material on the interior sides. b. Handwash sink was observed without a splash guard. Splash debris was visible along the edges of the sink. The sink was directly next to food prep area and clean dishes. Active food prep was occurring within the splash radius of the sink, causing potential contamination. c. Staff was asked for test strips to check the sanitizer bucket concentration. The provided strips indicated zero parts per million (PPM) of sanitizer in the bucket. The cook was asked when the bucket was made, and she did not know. The cook stated it was there when she arrived at facility at 8:00 am that morning. The cook validated the buckets should be changed every two hours and/or when soiled. Staff were unaware that the strips provided to surveyor were not testing for the active chemical from their wall dispenser. The surveyor was able to validate the chemical coming from the wall dispenser was dispensing at correct sanitizing concentrations (PPM). The cook validated that the facility did not have a system to track sanitation concentrations to ensure sanitizer buckets were changed timely and were at the correct PPM. d. Multiple potentially hazardous food items were noted stored without open dates. Multiple items were found past seven days of being opened/prepared. e. Kitchen staff did not have facial hair effectively restrained when preparing sandwiches. f. Multiple dome lids to cover plated food were noted to be melted/damaged and no longer providing a smooth, cleanable surface. At 1:00 pm the areas in need of cleaning, repair, and attention were reviewed with Staff 1 (Administrator). She acknowledged the findings.

1A- The ice machine was cleaned and added to a calendar for bi weekly cleaning unless it is determined that it needs cleaned more often. 1B- New splash guard was ordered and adhered to the sink so that it stays in place. It will be replaced as needed. 1C- Correct test strips implemented 1D- Labels were ordered that include open date, expiration date, and the product. 1E- Enforced facial hair restraint. 1F- Discarded dome lids with melted/damaged tops and ordered new ones. 2A- The ice machine will be cleaned bi monthly, and will be monitored for additional cleaning needs. 2B- A new, more durable splash guard was adhered to the counter. It will be monitored for durability and effectiveness. 2C- Correct Sanitizer strips were ordered and are available for use. A log is in place to monitor consistency and compliance, and training was conducted at all staff meeting. 3D- Staff educated on proper way to fill out labels, to include date received, date opened, expiration date, and product name. Food keeper app was shared with kitchen director and other staff. OHA Food Sanitation Rules were printed and placed in binder, located in kitchen director's office for reference. 2E- Staff educated on facial hair restraints and the requirement to wear one if you have facial hair. 2F- New dome covers were ordered and staff educated to not stack plates under heat lamp, which caused bubbling and ultimately uncleanable surfaces. 3. A,B,C,D,E,F- will be monitored weekly and ongoing, frequency increased as needed. 4-Dining Service Director and Executive director will monitoring these items and are responsible for staff training.

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

C455: Based on interview, observation and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

Refer to C 240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

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, record review and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 03/06/07 from 11:45 through 3:00 pm revealed the following deficient practices; a) Accumulation of, splatters, spills, drips, dust, black matter, food and other debris noted on: *Trays where clean dishes were stored; * Ceiling/walls above dish machine * Walls near hood vents; * Metal spice racks near/above stove; *Interior of ice machine; *Table top mixer; * Interior of reach in freezers; * Industrial can opener and housing; * Floor in front of ice machine under mat; * Floor and walls under dish machine; b) The following areas/items were found needing repair; *White Reach in freezer with large ice/frost build up. * Gaps/holes in ceiling where electrical conduit enter. * Metal shelving in dry storage. c. Kitchen staff observed to cook three burgers on the grill for resident meal service. No internal temperature was checked prior to service to ensure safe/palatable temperatures were reached. d. Kitchen staff were not observed to appropriately wash produce (lettuce/tomato) prior to service to residents who ordered hamburger/cheese burger. e. Surface sanitation buckets were noted at 0 ppm of sanitizer. Staff 2 (Dining Services Director) indicated buckets were switched every four hours. Staff 2 was not aware the requirement was every two hours. Upon further investigation it was determined the Quaternary sanitation solution coming out of the wall dispenser was also registering 0 ppm of sanitizer. Staff 2 was unaware how long there had been an issue with the dispenser. Staff 2 placed a call to vendor to fix the dispenser. Facility indicated they would hand mix the sanitizing solution until the dispenser could be fixed. f. Facility was using incorrect thawing/defrosting methods indicating they were running frozen whole cuts of meat under cold water for several hours the day or two before needed use. Staff 2 was unaware that quick thaw running cold method must be for immediate use (same or next meal). g. Staff 2 was unaware of the correct reheat temperature. The facilities cook to temperature guide did not include reheat temperatures for staff reference. h. The person In Charge did not demonstrate adequate knowledge in the following, surface sanitation and monitoring, safe reheat temperatures, correct thawing practices, and correct cooling methods. Staff 2 was also unaware of the requirement to ensure facility had Seven days of staple foods on hand. i. Multiple potentially hazardous food items were noted stored in both the main kitchen and the activities fridge without appropriate opened/prepared dates. Multiple items stored in the main kitchen was found past 7 days of opened/prepared. A container of egg salad was noted with a date of 01/28/25 well past 30 days. Staff 2 immediately discarded the outdated items. On 03/06/25, Staff 2 and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings. At 2:30pm the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Administrator). They acknowledged the findings.

1. (a) The following will be cleaned including accumulation of splatters, spills, drips, dust, black matter, food and other debris noted on: Trays where clean dishes were stored; Ceiling/walls above dish machine; Walls near hood vents; Metal spice racks next to stove; Interior of ice machine has been defrosted; Table top mixer; Interior of reach-in freezers; Industrial can opener and housing; Floor in front of ice machine under mat; and Floor and walls under dish machine. (b) Ice-build up on white reach-in freezer has been defrosted; holes in ceiling where electrical conduit enters has been repaired; dry storage metal shelving has been repaired. (c) Staff will measure internal temperature prior to serving meat moving forward, (d) raw produce will be appropriately washed prior to service, (e) Sanitizing dispenser was repaired; sanitizer bucket will be switched every 2 hours and mixed to appropraite concentration from this point forward, (f) correct thawing/defrosting methods will be used for all meat from this point forward, (g) All food will follow reheat to correct reheat temperature from this point forward, (h) Community will ensure that seven days of staple food is on hand; (i) food items will be dated with prepped /opened dates and discarded when outdated. All outdated food was destroyed during survey. 2. Cleaning checklist and schedule will be implemented and include review of refrigerated food for labels, outdated is thrown out; ensure 7 day staple food on hand; sanitizer bucket contain appropriate concentation. Supervision will be conducted to ensure that foods are being temped prior to serving, produce is apropriately washed and meat is properly defrosted prior to serve out. Inservice covering food prep, storage, cooking and kitchen cleaning will be conducted by 5/5/25 for all persons providing these services. Food storage guide has been posted in the kitchen. 3. Weekly for cleaning schedule; quarterly 4. DSD, ED

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, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 12/18/23 revealed splatters, spills, drips, dust and debris noted on: - Dining room floor underneath tables; - Interior of ovens; - Tray where clean dishes were stored; The following areas/items were found needing repair; - Interior of dish machine with heavy mineral buildup; - Floor underneath dish machine and ice machine with heavy mineral buildup; - Reach in refrigerator in dining room not maintaining appropriate temperatures for cold storage.   * Ice machine with visible black substance on interior where ice was stored. There was a notable mineral build up on exterior and interior of ice machine. * Reach in refrigerator in the dining room was found at 48 degrees Fahrenheit. Milk and other protein items noted stored in refrigerator. Milk temperatures was found at 48 degrees. It was determined kitchen staff were not consistently monitoring the temperature of that refrigerator and it was unknown how long those items were above 41 degrees. Staff 2 discarded all potentially hazardous food items. * Kitchen did not have a 3 compartment sink as required. * Dishwashing racks were observed overloaded with dishes/equipment not allowing all items unobstructed access to sanitizing agent. * Kitchen staff without restraint for facial hair. * Countertop mixer and equipment were not covered when not in use. * Scoops were observed stored in bulk food bins/containers. Staff 2 and the Surveyors toured the kitchen. Staff 2 acknowledged the above findings. At 1:20pm, the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Wellness Director). S/he acknowledged the findings.

Plan of correction for splatters, spills, drips, dust and debris- Dining room floor underneath tables, interior of ovens, tray where clean dishes are stored 1. All areas with splatters, spills, drips, dust and debris will be deep cleaned by kitchen staff  by 1/15/24. Initial cleanings occuring on a daily basis as of inspection date. 2. Updated cleaning schedule to include bi-weekly cleaning of oven and trays instead of monthly. Staff implementation of push broom after each meal. 3. Dining director will audit deep clean list at end of every month to ensure tasks are completed. Prior to leaving each shift, cook on duty will ensure dining room has been swept. 4. Dining Services Director, Executive Director and Residents Services Director will be responsible for monitoring and corrections. Plan of correction for items that were found needing repair- Interior of dish machine with heavy mineral buildup; - Floor underneath dish machine and ice machine with heavy mineral buildup; - Reach-in refrigerator in dining room not maintaining appropriate temperatures for cold storage. 1. The following items cannot be repaired and will be replaced: reach-in refrigerator in dining room. Replacement time is dependent on shipment time. Once arrived, Dining Director will check temp logs daily. Plant Operations Director has descaled the following areas with a descaling agent: interior of dish machine, floor underneath dish machine and ice machine. 2. Descaling of dish machine and ice machine will be added to the monthly cleaning checklist. Plant Operations Director and Dining Director will complete monthly walk-thru of kitchen and dining area to identify items needing repaired or replaced. 3. Dining Director will audit cleaning list monthly for completion. Plant Ops Director will verify proper working order of kitchen and dining monthly. 4. Dining services Director and Plant Ops Director Plan of correction for ice machine with visible black substance on interior where ice was stored. 1. Dining services director will deep clean ice machine, draining entire machine monthly and ensuring all interior areas are cleaned and sanitized. 2. After monthly deep clean, plants ops director will second initial that ice machine has been thoroughly cleaned. 3. Executive Director will review ice machine cleaning record and check ice machine cleanliness quarterly. 4. Dining services director and Executive Director Plan of correction for staff not consistently monitoring the temperature of reach in refridgerator in dining room 1. Broken refrigerator was unrepairable and disposed of immediately. 2. When new fridge arrives, cook-on-duty will check temperatures daily with all other temp logs. 3. Daily 4. Dining services Director will review temp logs weekly Plan of correction for kitchen not having three compartment sink as required. 1. Facility has received an exception for not having a three compartment sink 2. Two sink system policy will be implemented in the event dishwasher is not in good working order. 3. Exception is good until 1/3/2026 4. All staff will be trained on two sink system policy on 1/24/24. In this event, Dining services Director will ensure two sink system policy is followed. Plan of correction for dishwashing racks being overloaded with dishes/equipment not allowing all items unobstructed access to sanitizing agent 1. Dishwashing racks will be loaded so that all items have access to sanitizing agent 2.All staff meeting to provide training and demonstration on proper loading of racks in order to achieve proper sanitation requirements and observe return demonstration. 3. Weekly- Dining Director to do spot checks weekly to ensure appropriate method is being used 4. Executive Director and Dining Services Director. Plan of correction for kitchen staff without restraint for facial hair 1. Any cook with facial hair will wear beard net 2. Beard nets will be worn ongoing by all cooks with facial hair 3. Dining service Director to complete weekly spot checks 4. Dining Services director Plan of correction for countertop mixer and equipment not covered when in use- 1. Plastic bag was placed over countertop mixer when not in use 2. After each use and cleaning, a new plastic bag will be placed over countertop mixer while not in use 3. Daily 4. Cook on duty Plan of correction for scoops stored in bulk foodbins/containers- 1. Scoop in food bin was removed 2. All staff will be trained on expectation of scoops being stored in foodbins at all meeting on 1/24/24. 3. Daily 4. Cook on duty

The findings of the kitchen inspection, conducted 12/18/23, 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 revisit to the kitchen inspection of 12/18/24, conducted 04/10/24, 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 on-site investigation, conducted 12/15/23, 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 living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on interview and record review, it was confirmed that the facility failed to administer medications and prescribed. Findings include: In review of Resident # 1's medication administration records (MARs) and progress notes for February and December 2022. Resident #1 did not receive a medication for multiple days due to the medication "not in house, waiting on new script". The above information was acknowledged by Staff #1-2 on 02/07/23 and 02/14/23 via phone interview and email follow up. In a phone interview on 02/07/23, Staff #1 stated that the facility has had a couple of issues with the pharmacy, and they have filed a formal complaint regarding their concerns. Providers were signing electronically, and they are not able to fax the pharmacy with digital signature, so this was causing a delay. Plan of Correction: Facility has had group meetings with Hospice and the nursing team, talked to pharmacy to talk to providers, they recently had Survey at the building and are working with a consultant. They have also had some changes to their re-ordering process which seems to be working better.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/07/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: 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 interview and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#1). Resident 1 was sent unaccompanied via public transportation when s/he displayed an onset of neurological symptoms which necessitated immediate medical attention. Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2020 with diagnoses including hypertension. The resident's 09/08/22 through 01/08/23 service plans, temporary service plans, hospital discharge summaries, and progress notes were reviewed, and facility staff were interviewed. In a progress note dated 10/10/22 at 7:44 pm, facility staff documented the resident displayed the following symptoms "around 1PM": * "[Signs and symptoms] of confusion and disorientation"; * "Unable to complete sentence"; * "Was unsure of where [s/he] was supposed to be going, or how to explain what [s/he]  was supposed to be doing."; * "Resident stated [s/he] had numbness in [his/her] hands in the morning"; and * "Was shaking when assessed by med tech." Staff documented the resident had a scheduled a physician's appointment at 2:45 pm. The facility had the resident transported unaccompanied via public transportation to the physician's office. The resident was subsequently transported via ambulance, at the request of the physician, to the local hospital and admitted for assessment for "a possible stroke." The resident was released from the hospital on 10/11/22 with diagnoses of a mass in his/her upper lung, transient ischemic attack, and dysphasia. The facility's failure to provide immediate medical attention when Resident 1 exhibited a sudden change in neurological symptoms placed the resident's health, safety, and welfare at risk. The documentation related to the events identified above was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/23. The failure to exercise reasonable precautions when the resident displayed neurological symptoms which necessitated immediate medical attention was discussed with them at that time. No further documentation was provided.

Plan of correction for tag C 160 1. The resident needs were evaulated by the hospital, upon return needs were evaluated by nursing and a plan of care was updated and implemented based on new care needs. All staff will be trained by 3/13/23 in change in condition and emergency response and transfer. 2. Changes in condition will be assessed timely. Staff will initiate ermegency medical services if conditions needing immediate medical attention. 3. Timely in response to each incident 4. Wellness Director or Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was treated with dignity and respect. Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2020 with diagnoses including hypertension. Review of the resident's 09/08/22 through 01/08/23 progress notes, the 11/22/22 service plan, and interviews with staff and the resident revealed the following: During an interview with the resident on 01/09/23, when asked how s/he was doing, the resident replied that s/he wasn't doing very well because staff "won't let me get out of bed." Instructions to staff reviewed in Resident 1's 11/22/22 service plan stated, "Staff are not to transfer [Resident 1] if [s/he] is unable to hold [his/her] weight up when standing. Staff are to provide care in bed if [Resident 1] is not able to transfer." In an interview with Staff 13 (CG/MT) on 01/09/23, she confirmed staff were instructed not to get the resident up if s/he was unable to bear weight. A discussion related to the above was conducted on 01/09/23 with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN). They acknowledged the resident's right to be treated with dignity and respect, and to get out of bed if s/he chose.

Plan of correction for tag C 200 1. Resident's care plan was updated to support resident's rights and plan for transfers per resident request.   2. Facility will ensure all resident rights are upheld and a plan is in place for resident's transfer needs and ability to move about the community.   3. Quarterly 4. Executive Director or Wellness Director

Based on interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were investigated to rule out abuse for 1 of 1 sampled resident (#1) reviewed with incidents. Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2022 with diagnoses including hypertension. Review of incident investigations, dated 10/08/22 through 01/08/23, temporary service plans, and progress notes revealed the following: In an incident investigation dated 11/18/22, staff documented Resident 1 sustained bruises to his/her left upper arm, "around the whole knee," and bruising to his/her left shin, when his/her scooter "tipped slightly" while s/he was being transported in the facility van 11/17/22. During an interview, Staff 17 (Van Driver) confirmed that even though he had secured Resident 1's scooter with straps, when he turned a corner the resident's scooter tipped "partially" over. While recounting the incident in the van, Staff 17 demonstrated resident's position after the incident and stated s/he was "kind of hanging." The facility investigation indicated abuse was ruled out as the resident was "tilted too far over in [his/her] chair." There was no documented evidence the facility immediately investigated whether or not Resident 1's scooter had been secured properly in the van or if the resident had sustained any injuries as a result of "partially" tipping over. The investigation failed to include the response of staff at the time of the event and follow-up actions. On 11/18/22 the resident was transported to the emergency department "due to not being able to put pressure on the left leg. Resident was complaining of pain from [his/her] knee to [his/her] hip." Review of the after-visit summary from the emergency department indicated the  resident was diagnosed with a fall and traumatic ecchymosis (bruise) of the left lower leg. The need to ensure all incidents of abuse or suspected abuse were immediately investigated to rule out abuse and document follow-up actions related to the event was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23 and 01/11/23. They acknowledged the lack of documentation related to the incident.

Plan of correction for tag C231 1. Resident was sent to ER for evaluation upon discovery of injury. Incident was reviewed and documented on. Van driver was trained and properly demonstrated securing residents in vehicle on 11/18, including appropriate wheelchairs that can be secured in the van. Training will be conducted 2/22 with ED/WD regarding timely assessment, investigation and documentation of incidents. 2. All incident will be timely investigated and reviewed, including documentation of incident and implementation of updated careplan and interventions. Suspected abuse / neglect will be reporting approrpaitely per Abuse and Neglect Reporting Guidelines. 3. As incidents occur and prior to deadline for reporting suspecte abuse. 4. Executive Director or Wellness Director

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and provided clear direction to staff for 1 of 4 sampled residents (#1). Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2020 with diagnoses including essential hypertension. Review of the resident's 11/21/22 service plan and outside provider notes, observations of the resident, and interviews with staff revealed the following: * The service plan instructed staff to "provide escort in manual WC [wheelchair] to all meals and activities." A wheelchair was not observed in the resident's room during an interview with him/her on 01/09/23. Staff 13 (CG/MT) stated the resident did not have a manual wheelchair. * Review of hospice provider notes from 11/22/22 through 01/09/23 revealed hospice provided a bath aide for the resident. There was no indication of this on the service plan. * The service plan indicated the resident had a hospital bed and urinary catheter. The service plan lacked direction to staff related to the hospital bed and care of the catheter. The need to ensure the service plan was reflective of the resident's current care needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/22 and 01/12/22. They acknowledged the deficiencies in the service plan.

Plan of correction for tag C 260 1. Resident #1 care plan was updated in all of cited areas listed. RN consultant is auditing current care plans to ensure that they reflect current care needs. 2. Consultant is providing training on how to ensure accurate service plans that reflect all resident needs. Consultant has provided service plan checklist for nursing to utilize to capture all care needs. All service plans will be reviewed by ED, WD and RN upon admission, at the 30 days, quarterly and with any significant change of condition. 3. Resident admission, 30 day review, quarterly and significant change in condition. 4. Executive Director, Wellness Director

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were evaluated and referred to the RN, and short-term changes had actions and interventions determined, documented, communicated to staff on all shifts, made part of the resident record, and with weekly progress noted through resolution for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2022 with diagnoses including hypertension. Review of the resident's facility records identified the following: a. In a progress note dated 10/10/22, facility staff documented the resident experienced increased confusion, language difficulties, and numbness in his/her hands. This constituted a significant change of condition as it was a major deviation in the resident's health. There was no documented evidence the facility evaluated the resident and referred him/her to the RN. Refer to C160. b. An 11/18/22 incident investigation stated the resident's scooter partially tipped over in the facility van on 11/17/22, and the resident sustained bruises on his/her left upper arm, knee, and shin. An 11/18/22 progress note indicated Resident 1 was transported to the emergency department "due to not being able to apply pressure on the left leg. Resident was complaining of pain from [his/her] knee to [his/her] hip." Review of the after-visit summary from the emergency department indicated the resident was diagnosed with a fall and traumatic ecchymosis (bruise) of the left lower leg. There was no documented evidence the facility evaluated the resident after the incident, developed actions and interventions related to the resident's care, communicated them to staff on all shifts, updated the service plan, and monitored the bruises at least weekly to resolution. c. A 12/30/22 incident investigation indicated Resident 1 had a documented fall from bed on that day, hit his/her head, and sustained a bruise on his/her right forearm. Latent bruising on the resident's right shoulder and arm was documented by the hospice nurse on 01/03/23. There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident after s/he sustained the injuries, and communicated them to staff on all shifts. The need to ensure significant changes of condition were evaluated and referred to the RN, and short-term changes had actions and interventions determined, documented, communicated to staff on all shifts, made part of the resident record, and with weekly progress noted through resolution was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23 and 01/11/32. They acknowledged the lack of documentation related to Resident 1's medical condition.

Plan of correction for tag C270 1. Resident #1 was sent to hospital and assessed for change in condition after incident. Resident has currently been assessed and actions and interventions have been determined, documented, and communicated to staff on all shifts, made part of the resident record, and will be weekly assessed with progress note until deemed stable/resolved or updated actions/interventions and documentation are required. Training was provided by March 3, 2023 regarding change in condition moniroting and seeking emergency response. 2. Changes in condition will be assessed timely. Changes identified as signficant as outlined in OARs, will be notied to RN for assessment. Documentation will be timely. 3. Timely as changes occur. 4. Executive Director, Wellness Director and RN as applicable

2. Resident 1, admitted to the facility in 02/2020, was identified during the acuity interview to be receiving hospice services. Review of the resident's 11/23/22 service plan, 11/23/22 through 01/08/23 temporary service plans, progress notes, hospice visit summaries, and the 12/01/22 through 01/08/22 MAR revealed there was no documented evidence the facility implemented the following recommendations or updated the service plan as applicable: * 12/1/22: "Apply cool wet washcloth to left knee for comfort"; * 12/2/22: "Recommend offering pain medications and administer prior to any ADL cares to maintain comfort ...and improve participation in ADL cares"; * 12/7/22: Resident reported "pain in shoulders and heel ... displays signs of pain when moving right leg ... Premedicate with PRN pain meds prior to repositioning/brief changes if indicated. Continue to use cold wash cloth on knee for pain"; * 12/11/22: "Give PRN Miralax today"; * 12/18/22: "Give PRN Miralax today"; * 12/19/22: "Apply cream to bilateral LE's [lower extremities] BID ... Continue to monitor superficial open area to gluteal cleft. ... Monitor to ensure catheter is secured to thigh"; * 12/23/22: "Encourage fluids"; * 12/28/22: "Encourage fluids"; and * 01/03/23: "Monitor discoloration to R [right] shoulder and arm. Notify hospice of increased pain." The hospice provider visit notes were reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/23. They acknowledged the deficiencies identified above.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers, by failure to incorporate recommended interventions into the service plan for 3 of 3 sampled residents (#s 1, 4, and 5) who received outside services. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2021, with diagnoses of heart disease, osteoporosis, and lumbar fracture. Resident 4's service plan, dated 12/01/22, temporary service plans (TSPs), progress notes, and outside provider notes, dated 10/11/22 through 01/09/23, were reviewed. The records indicated Resident 4 had received outside services for Occupational Therapy (OT), Physical Therapy (PT), and Home Health Nursing. The outside provider notes included the following recommendations: * 01/06/23: "Assist in HEP [home exercise program] with yellow theraband"; * 12/26/22: "Please encourage [him/her] to get into [his/her] wheel chair for seated exercises"; * 12/21/22: "Use antipressure booties to float heels while in bed"; and * 12/21/22: "Please assist with exercises, and stabilize feet at ankles and knees during bridging. Also help [him/her] scooting to HOB [head of bed] with BLE [bilateral lower extremities] bent, and [s/he] assists by 'walking' self up." There was no documented evidence any of these outside provider recommendations were addressed in TSPs or incorporated into Resident 4's service plan. In an interview on 01/12/23, Staff 1 (Executive Director) acknowledged the lack of continuity of care regarding provider recommendations. Staff 1 stated, "Yes, we are aware of the problem with the system and are working on it." On 01/12/23 the need to add recommended interventions to the resident's service plan was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), and Staff 3 (RN). They acknowledged the failure to include outside provider recommendations in the resident's service plan. 3. Resident 5 was admitted to the facility in 10/2019 with diagnoses including history of cerebral infarction. The resident's record, including the current service plan and temporary service plans (TSPs), progress notes, and outside provider notes dated 10/03/22 through 01/09/23, were reviewed, and the resident and staff were interviewed. The following was identified: * The resident experienced a stroke on 10/03/22 and was admitted to the hospital, after which s/he was sent to a rehab facility. The resident returned to the facility from rehab on 11/04/22. * Home health services, including PT and speech therapy, began in 11/2022. * Between 11/09/22 and 01/02/23 there were 14 home health visits. * On nine of the 14 home health visits, the PT or speech therapist made recommendations related to resident care. There was no documented evidence the recommendations were communicated to staff or implemented. On 01/11/23, Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) explained they used TSPs to communicate and implement outside provider recommendations. In interviews on 01/12/23, Staff 1 and Staff 2 both reported they were unable to locate any TSPs which corresponded with the recommendations made by home health on the nine occasions noted above. The need to follow through on recommendations made by outside providers was discussed with Staff 1 and Staff 2 on 01/11/23 and 01/12/23. They acknowledged they had not followed-up on PT and speech therapy recommendations. No further information was provided.

Plan of correction for tag C 290 1. All outside provider current recommendations will be added to resident care plans. 2. Outside service forms will be reviewed timely for changes to plan of care. Temporary service plans and training will be implemented as needed per outside service recommendation. 3. Third party notes will be reviewed on working days. Careplans will be updated with permanent changes at the 30 days, 90 day and for change in condition. 4. Executive Director, Wellness Director

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to: During the re-licensure survey, conducted 01/09/23 through 01/12/23, the medication system was found to be ineffective in the following areas: 1. Multiple instances were identified where 2 of 4 sampled residents (#s 4 and 5) did not receive prescribed medications for up to eight days because the facility was waiting for the pharmacy to deliver the medication. 2. Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas: * C302 Systems: Tracking Control Substances; * C303 Systems: Treatment Orders; and * C310 Systems: Medication Administration. The need to ensure a safe medication system and to ensure adequate professional oversight was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23. They acknowledged the lack of a safe medication system and professional oversight.

Plan of correction for tag C 300 1. Resident #4 and 5 MARS were reviewed for accuracy and to ensure all medications were available and accessible to be given as ordered. Community is receiving medications via on-demand process to ensure medications are available for administration. 2. Missed medication report reviewed  by med techs prior to completing shift. Routine audits for 7 day supply will be conducted twice weekly. All med orders will be reviewed through three check system, which includes checking availability or investigating barriers to availability. All follow up with be documented. 3. Weekly and quarterly. 4. Executive Director, Wellness Director, Resident services director

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#1) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2022 with diagnoses including hypertension. Review of Resident 1's 01/01/23 through 01/09/23 Controlled Substance Disposition logs and MARS, revealed seven doses of morphine sulfate solution were initialed as given on the MAR, but were not reflected on the disposition log. The MAR and Controlled Substance Disposition Logs were reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/12/23. They acknowledged the discrepancies between the two documents. The need to ensure an accurate narcotic disposition log was maintained for all controlled substances was discussed at that time. Staff 1 and Staff 2 acknowledged the findings.

Plan of correction for tag C 302 1. Documentation will be reviewed for accuracy in both the MAR and the controlled substance log. On the spot immediate training was provided to med techs on how to accurately dispense controlled substances. Medtech meeting completed 1/25. 2. Monthly med tech meeting completed on 1/25 and appropriate administration of controlled substances reviewed. Elderwise consultant will provide controlled substance audit. Routine audit of narc book to MAR for accuracy. All discrepancies will be reported to WD per protocol. 3. Quarterly and and as needed 4. Wellness Director, RSD

2. Resident 1 was admitted to the facility in 02/2020 with diagnoses including hypertension. Review of the resident's 12/02/22 physician orders, the facility's bowel tracking log, and the 12/02/22 through 01/08/23 MARs revealed the following: * Cavilon barrier cream (for skin breakdown) and fluticasone nasal spray were ordered to be administered daily, but listed as PRN on the MAR. The medications were not administered to the resident during the time frame reviewed. * There was no documented evidence of a physician order in the resident's facility record for PRN Milk of Magnesia (for constipation), which was administered on 12/24/22 and 01/04/23. * Physician orders for PRN bowel medications for constipation indicated staff were to administer Miralax on day two without a bowel movement, Senna on day three without a bowel movement, and a bisacodyl suppository on day four. Documentation on the MAR indicated the medications were not administered to the resident in the time frame ordered by the physician on multiple occasions. The MAR and physician orders were reviewed with Staff 1 and Staff 2. They acknowledged the discrepancies documented above. The need to ensure there were signed physician orders in the resident's facility record for all medications the facility was responsible to administer and orders were carried out as prescribed was discussed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/23. 3.  Resident 4 was admitted to the facility in 12/2021 with diagnoses of heart disease, osteoporosis, and lumbar fracture. Review of Resident 4's MAR, dated 12/01/22 through 01/09/23, and physician orders, dated 12/05/22, identified the following deficiencies: The following scheduled medications had missed doses on the dates shown, with the reason listed as "awaiting delivery": * Senna-Time 8.6 mg (for constipation): 12/06/22, 12/07/22, 01/06/23, 01/07/23, 01/08/23; * Carvedilol 3.125 mg (for heart health): 12/07/22, 12/08/22, 12/09/22, 12/10/22, 01/08/23; * Oyster Shell Calcium 500 mg (supplement): 12/07/22, 12/08/22, 12/09/22, 12/10/22, 01/08/23; * Acetaminophen 325 mg (for arthritis): 12/10/22; * Modafinil 100 mg (for sleep apnea): 12/12/22; * Clopidogrel 75 mg (for chest pain): 12/14/22, 12/15/22; and * Atorvastatin 10 mg (for high cholesterol): 01/08/23. While the facility was awaiting delivery of these medications, the resident was not receiving them, which constituted failure to follow physician orders. On 01/12/23 the need to ensure all written orders were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN) and Staff 3 (RN). They acknowledged the findings, and Staff 2 stated the facility was working to improve the medication systems.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and all medication and treatment orders were documented in the resident's facility record for medications and treatments the facility was responsible for administering for 3 of 4 sampled residents (#s 1, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 10/2019 with diagnoses including diabetes. Review of the resident's 12/01/22 through 01/09/23 MARs and physician orders revealed the following deficiencies: a. The resident missed doses of the following scheduled medication on the dates listed, with the reason given as "awaiting delivery": * Amlodipine Besylate 10 mg (for hypertension): 12/05/22, 12/06/22; * Atorvastatin 40 mg (for cholesterol): 12/10/22, 12/11/22, 12/12/22, 12/13/22, 12/14/22, 12/15/22, 12/17/22; * Glipizide 5 mg (for diabetes): 01/04/23, 01/05/23, 01/06/23, 01/07/23; and * Lisinopril 10 mg (for hypertension): 12/05/22, 12/06/22. While the facility was awaiting delivery of these medications, the resident was not receiving them, which constituted failure to follow physician orders. b. The resident had the following orders for Lisinopril (for blood pressure): * 12/06/22 5 mg once a day; * 12/08/22 10 mg once a day; and * 12/13/22 10 mg once a day. From 12/08/22 through 01/09/23 the resident was administered 5 mg per day of Lisinopril. In an interview with Staff 2 (Wellness Director/LPN) on 01/10/23, she verified there were discrepancies between physician orders for Lisinopril and what was administered to the resident. The need to carry out physician orders as prescribed was discussed with Staff 1 (Executive Director) and Staff 2 on 01/10/23. They acknowledged the findings, and both reported they had begun to make changes to the medication administration system.

Plan of correction for tab C 303 1. Resident 1,4 and 5's eMAR's were reviewed for accuracy, current physician orders were obtained for all medications, clarification or discontinuation of orders were obtained and all medications are on site. Facility inplement new ordering system for timely delivery of medications. 2. Missed medication report will be reviewed each shift by med staff and supply availablility reviewed twice a week. Routine audit of MARS for holes and exceptions. 3. Weekly and quarterly. 4. WD and RSD

2. Resident 1 was admitted to the facility in 02/2020 with diagnoses including hypertension. Review of the 12/01/22 through 01/08/22 MARs and current physician orders revealed the following: * Quetiapine, Lisinopril, fluticasone lacked reasons for use; * PRN Senexon (for constipation), discontinued on 12/28/22 by the physician, was still listed on the MAR as of 01/09/23; and * Multiple bowel medications identified on the MAR to be administered for constipation lacked clear parameters and instructions to staff related to the sequence in which to administer the medications. The MAR was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/11/23. They acknowledged the deficiencies referred to above. The need to ensure the MAR was accurate and included resident-specific parameters and instructions for PRN medications was discussed with and acknowledged by Staff 1 and Staff 2. 3. Resident 5 was admitted to the facility in 10/2019 with diagnoses including hypertension and diabetes. Review of the resident's 12/01/22 through 01/09/23 MARs and physician orders revealed the following: * On the 12/2022 MAR, two medications lacked reasons for use: - Preservision AREDs; and - Warfarin. * The 12/2022 MAR indicated Atorvastatin had been initialed as administered on 12/16/22, but marked as "awaiting delivery" 12/10/22 through 12/15/22 and on 12/17/22. * Calmoseptine ointment was ordered to be administered twice daily; the 8:00 pm administration on 12/05/22 was left blank. * On the 01/01/23 through 01/09/23 MAR Glipizide had been initialed as administered on five occasions between 01/04/23 and 01/07/23 and marked as "awaiting delivery" on three occasions. * Also on the 01/01/23 through 01/09/23 MAR, three medications lacked reason for use: - Glipizide; - Preservision AREDS; and - Warfarin. The need to ensure the MAR was accurate was discussed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23. They acknowledged the findings and stated they had provided training to MTs about documenting accurately on the MAR and planned to continue the training.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 3 of 4 sampled residents (#s 1, 2, and 5) whose MARs and physicians orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2022 with diagnoses including chronic viral Hepatitis C and prostate cancer. A review of Resident 2's 12/01/22 through 01/09/23 MAR identified the following medications lacked a reason for use: * Bupreno-Nalox 2-0.5 mg sl tab; * Insulin glargine-yfgn U100 pen; * Loratadine 10 mg tablet; * Polyethylene glycol 3350 powder; * Sebex shampoo; * Simvastatin 20 mg tablet; * Spironolactone 25 mg tablet; * Tamsulosin hcl 0.4 mg capsule; * Venlafaxine hcl 75 mg tablet; * Wixela 100-50 Inhub; and * Xtandi 40 mg capsule. The need to ensure MARs included a reason for use for all medications was discussed with Staff 4 (Regional RN) on 01/09/23 and with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), and Staff 3 (RN) on 01/12/23. They acknowledged the deficiencies on the MAR.

Plan of correction for tag C 310 1. Resident's 1,2 & 5 MARS were updated to reflect indications for use. Parameters were written for all PRN medications. Clear parameters and instructions were written related to the sequence in which to administer medications when there are multiple medications with same diagnoses 2. Third checks are performed on each medication order to ensure med process is complete, including PRN parameters and indication for use. Routine clinical meetings are held to verify third check process. 3. Quarterly MAR audits. WD will pull PRN parameter audit weekly. 4. Executive Director, Wellness Director, RN as applicable

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 11, 13, and 15) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to: Staff training records were reviewed on 01/10/23. There was no documented evidence Staff 11 (MT), Staff 13 (CG/MT), or Staff 15 (CG), hired 03/16/12, 09/22/17, and 03/12/18, respectively, had completed a minimum 12 hours of annual in-service training related to the provision of care, at least six of which needed to be related to dementia care. The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Executive Director) and Staff 2 (Wellness Director/LPN) on 01/10/23. They acknowledged the lack of annual training hours for long-term staff.

Plan of correction for tag C 374 1. Full training audit completed and training completion in process. All staff training completed 1/25 which included 1.5 hours dementia training. 2. Employee training assigments will be scheduled upon hire and routinely audited for completion. 3. Quarterly and annually. 4. Executive Director, Wellness Director and RSD

The findings of the re-licensure survey, conducted 01/09/23 through 01/12/23, 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 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 first revisit to the re-licensure survey of 01/12/23, conducted 05/15/23 through 05/16/23, 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 Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, record review and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 12/27/22 revealed splatters, spills, drips, dust and debris noted on: - Can opener blade and casing; - Exterior of the range, range top, back of grill, and grease trap; - Underneath shelving and equipment; - Wire racks storing dishes; - Plate warmer; - Service/utility carts; - Light switches; - Dish machine; - Floor and walls under and behind dish machine; - Walls above and behind prep area; - Hand washing sink; - Corners/edges of door thresholds; - Chemical storage room floors/edges; - Hood above dish machine; - Microwave exterior and interior; - Plate warmer; - Trays where clean dishes were stored; - Pan where jugs were stored by the grill; - Exterior of refrigerators/freezers; - Walls and floors in chemical storage room; and - Walls as you entered the kitchen across from the service area. The following areas/items were found needing repair; - Hole in the wall in the dry storage area next to an outlet; - Under sink in dish washing area; - Multiple areas in door thresholds with chipped paint exposing wood; - Wood shelf where dishwashing chemicals were stored; - Interior of dish machine with heavy mineral buildup; - Wire racks storing dishes with areas of rust and ware; and - Freezer in chemical storage room with heavy frost/ice build up. * Cutting boards found with deep scoring and staining. * Steam table with large wooden area that was deeply scored/damaged making it a non cleanable surface. * Removable vents of hood above grill/stove with visible dust and build up. * Multiple items in the cold storage were not dated when prepared or opened. * Serving scoop was left in a dessert item and was stored uncovered in the refrigerator. * Prepared dessert items for service stored in fridge uncovered. * Multiple items in dry storage not dated when opened. * Brooms stored on floor. * Facility was not using pasteurized eggs. * Ice machine with visible black and pink substances on interior where ice was stored. There was a notable build up of dust on the intake vents on both sides of the ice machine. * Beverage service area in dining room was found with drips and spills on the walls. Small refrigerator in that area also with items not dated and spills and food/beverage stains or debris. * Kitchen staff observed touching ready to eat food products (fried chicken/lettuce for salads) with gloves that had touched other potentially contaminated items (service utensils, fridge door handles, knife). * Dish machine was found not reaching necessary temperature for sanitization and thermometer was not working for rinse cycle. Facility discontinued use of dish machine and utilized alternated methods for sanitizing pots and pans and switched to use of paper products until dish machine could be fixed. Service company contacted by Staff 2 (Dining Service Manager) and Staff 3 (Maintenance) and indicated they would be out the next day to service/repair. Staff 2 and 3 indicated facility does have plans to replace dish machine in February related to ongoing repair issues with machine. Staff 2 and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings. The areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). She acknowledged the findings.

Plan of correction for splatters, spills, drips, dust and debris- 1. Deep clean of entire kitchen, chemical storage area, kitchen walls, ice machine and beverage service area will be completed on 2/8/23.  Initial cleanings occuring on a daily basis as of inspection date. 2. Updated monthly kitchen cleaning schedule to include all items listed on citation page 3, also including ice machine, beverage service area, chemical storage and small refrigerator. Ice Machine has been cleaned since inspection to resolve any immediate issues. 3. Dining Director will audit deep clean list at end of every month to ensure tasks are completed. 4. Dining Services Director and Executive Director will be responsible for monitoring and corrections. Plan of Correction for items that were found needing repair- 1. Maintenance requests were entered for all items and repairs to be completed by 2/13/23. The following items cannot be repaired and will be replaced- dishwasher, steam table, wire rack that stores dishes, cutting board, can opener and chemical storage rack. Replacement time is dependent on vendor availability and shipment time. (Facility is aquiring a new dishwasher. Until new dishwasher arrives we are using a santizier in replacement of high temp sanitizing. This will alleviate any inappropriate temperature issues.) Once new machine arrives, Maintenance Director will  complete monthly temperature checks on dishwasher for on-going maintenance.  Currently dishwasher has been converted to a low temp chemical (chlorine based sanitizer) system as a temporary solution. 2. Dining Director and ED complete quarterly standard audits. At quarterly dining standard audits ED will submit maintenance requests for any items found to broken or inoperable. Dining Director will submit requisitions to ED when kitchen items have become inoperable beyond repair. 3.  Dining Director will complete monthly and quarterly audits. ED will complete quarterly audits. 4. Dining Director, Maintenance Director and ED will be responsible for monitoring and corrections. Plan of correction for staff related issues- non-dated items, improper food storage, broom storage, food serving sanitation- 1. On 1/25/23 an all staff inservice will be completed to include food sanitation practices, cleaning and sanitizing protocols, proper food storage and proper serving protocols.  Documentation will be available upon request. 2. Dining Director will perform quarterly cook audits to ensure each cook is trained and knowledgeable on kitchen sanitation practices. This will include a skills checklist. ED will complete dining standards audit every quarter, to include observation of a meal service, meal preparation and food storage. 3. Dining Director is responsible for day to day monitoring of kitchen staff skills, education and conduct. Dining Director will perform quartely skills audit and ED will perform quarterly dining standards audit. 4. Dining Director , Executive Director will be responsible for monitoring and corrections.

The findings of the kitchen inspection, conducted 12/27/22, 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 12/27/22, conducted 03/30/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/23/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: 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

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/23/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: 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

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/23/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: 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

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/23/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: 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 Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/18/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: 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