Spring Valley Assisted Living

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.

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 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.

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.

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 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

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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.

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 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 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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a dayAssisted 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day