Spruce Point 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, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to: Observation of the Main kitchen on 07/02/25 at 11:11:15 am through 1:30 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Interior of ice machine; * Flooring in door thresholds, corners, edges, between and under equipment; * Industrial can opener and housing; * Wall next to dishwashing area; * Top of dishwasher * Wall behind dishwasher * Plastic racks in walk in cooler * Interior of drawers storing cooking equipment/utensils * Wall near/behind reach in cooler; * Metal shelving next to grill * Metal shelving where Microwave and other items stored * Flat top grill edges * Floors and walls behind major equipment * Interior of cabinets/drawers in dining room * Small sauté pan with noted dried food debris on food and non food contact surfaces and “ready to use” b. The following areas were found in need of repair: * Section of flooring in dishwashing area missing/pealing leaving uncleanable surfaces * Large scale accumulation in and around dish machine * Reach in freezers with large ice accumulation * Walk in freezer with visible large chunk/block of ice accumulation left of door. * Reach in freezer with cracked/broken seal * Reach in freezer with small gap in seal/freezer not closing completely c. Multiple cutting boards found heavily scored and in need of replacement in poor repair. d. Small fry/sauté pan stored on pile of dirty/soiled white kitchen towels. The dirty towels were touching the food contact surface. e. Staff observed to serve a cook to order cheeseburger without checking the final cook to temperature. Surveyor intervened and had facility check the temperature. Item was noted to be at 135 degrees Fahrenheit. Staff member incorrectly stated required cook to temperatures for ground meats. Surveyor ensured the cheeseburger was correctly cooked to temperature at 155 degrees or higher as required. f. Cook was observed multiple times to wash hands for less than 10 seconds, not the 20- 30 seconds as required to effectively wash/clean hands. Cook was also observed to not remove gloves when changing tasks as required. g. An employee drink was observed stored in the clean dishes section of the dish area and was not of the approved style posing a potential for contamination. h. Multiple kitchen rags for cleaning and sanitizing were noted stored randomly about the kitchen on counters and/or floors. No sanitizer bucket was found/noted for where the cleaning/sanitizing rags should be stored. Surveyor reviewed above areas with Staff 2 (Dining Services Manager) and they acknowledged the identified areas. At approximately 1:30 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (administrator) who acknowledged the areas.

OAR411-054-0030 TAG 0240 A) An accumulation of food spills, splatters, loose food and trash debris, dirt, duts, black matter and gease was visible on or underneath in kitchen: 1) Actions: The accumulation of food spills, splatters, loose food and trash debris, dirt, black matter, and grease were cleaned and removed. 2) The system of cleanliness of the kitchen will be corrected by creating new cleaning schedules daily, weekly, and monthly. 3) Weekly and monthly audits will conducted to keep close monitoring of the correction of these prior deficiences. 4) Kitchen Manager Jim McCoey will be responsible to the that the corrections are completed and monitored. B) The following areas were repaired or replaced. 1) Actions taken: * Flooring in front of dishwashing area was repaired *Scaling in and around dish washer was removed * Ice removed in walk in freezer *Seal in freezer was repaired and able to close completely * Memory Care refridgerator replaced. 2) Maintenance schedules for equipment will be properly done. 3) Daily and monthly audits will be done to ensure equipment is maintained and in working order. 4) Kitchen Manager Jim McCoey and Maintenance Director Angel Chavez will be responsible for completion and monitoring. C) Multiple cutting boards found heavily scored and in need of replacement in poor repair. 1) Action: The cutting boards in poor repair were replaced 2) Close observation of cutting boards will take place. 3) The cutting boards will be observed and monitored on a monthly basis 4) Kitchen Manager Jim McCoey will be resposible for monitoring the need of replacement of cutting boards. D) Small fry/ saute' pan stored on pile of dirty/soiled white kitchen towels. The dirty towels were touching the food contact surface. 1) Action: Saute' pan was removed along with the dirty soiled towels 2) Staff retrained on cleaning of pans, proper storage techniques and removal of soiled towels 3) The staff will be closely monitored on a daily, weekly, and monthly basis and training and coaching will be given on an ongoing basis. 4) Kitchen Manager Jim McCoey will be responsible for monitoring and training. E) Proper food temperatures and temping: 1) Action: Staff training on proper food temperatures and tempting of all meats before served has been done and signs are also posted through out kitchen for reminders. 2) Staff retrained on proper temping and food temperatures. 3) The staff will be closely montiored on a daily, weekly, and monthly basis and training and coaching will be given on an ongoing basis. 4) Kitchen Manager Jim McCoey will be responsible for monitoring an training. F) Hand Washing Etiquette 1) Action: Staff have been retrained on proper hand washing etiquette and hand wasing signs are posted. 2) Staff will have continuous monitoring and coaching on proper hand washing etiquette on a daily basis. Signs posted to remind staff of proper techniques in hand washing. 3) Staff will be monitored daily. 4) Kitchen Manage Jim McCoey will be responsible for training and monitoring. G) An Employee drink was observed stored in the clean dishes section and not of the approved style posing a potential for contamination. 1) Action: Staff has been instructed on porper ways to store drinks and the approved cups for storing drinks in the kitchen 2)Staff will be instructed ongoing bases on proper storage and proper containers. 3) Staff will be monitored daily. 4) Ktichen Manager Jim McCoey will be responsible for training and monitoring. H) Multiple kitchen rags for cleaning and sanitizing were noted sored randomly about the kitche on counters and/or floors. No sanitizer bucket was found/ noted for where the cleaning/ sanitizing rags should be stored. 1) Action: Staff have been instructed to only store rags near or in santizing buckets. 2) On going training will be given daily, weekly, and monthly. 3) Staff will be monitored daily. 4) Kitchen Manager Jim McCoey will be responsible for training and monitoring. OAR411-057-0140 MEMORY CARE TAG Z0142 I) Care staff were observed assisting with dining without protective barriers/ aprons. 1) Care staff have been equipped with aprons 2) Staff will wear aprons every time they serve food in dining room. 3) The staff will be monitored daily 4) Memory Care director Cassandra Sprague will monitor and train on wearing aprons during food service. J) Menus were not posted for residents/ families/ vistors to access 1) Menus are now posted in Memory Care for viewing 2) Posting of menus will be monitored to be sure up to date daily 3) The menus will be monitored daily 4) Memory Care director Cassandra Sprague will be responsible to see that the menus are always posted.

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, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to: Observation of the kitchen on 7/12/23 at 11:20 am through 2:30 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Interior of ice machine; * Flooring in door thresholds, corners, edges, between and under equipment; * Ceiling, vents and fire sprinklers; * Fan cage in walk in cooler; * Interior of reach in fridges and freezers; * Industrial can opener and housing; * Interior of ovens; * Food processor base; * Interior of microwave; * Industrial and countertop mixer; * Utility carts; * Wall behind and under ware washer; * Area on wall and floor under the sprayer in ware washing area; and * Freezer and cooler floors under racks. b. The following areas were found in need of repair: * Caulking behind hand washing sink; * Caulking in ware washing area had large accumulation of black mold like substance; * Large metal grate to grease trap by ware washer was rusted/corroded; * Fire sprinkler by hood was very corroded and large accumulation of dust/dirt and debris; and * Small holes/open areas observed in walls under dish area and where pipes or electrical conduit were located. c. Multiple cutting boards and utility carts were found damaged and in poor repair. d. Industrial and countertop mixer found not covered when not in use. e. Facility not using pasteurized eggs for undercooked egg foods like poached, soft fried eggs. f. Multiple Staff member preparing and/or serving food did not have hair/facial hair effectively restrained as required. g. Scoops were found stored in bulk food item bins. Surveyor reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas.  At approximately 2:00 pm the surveyors reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator). Staff 1 acknowledged the areas.

C240 A) The accumulation of food spills, splatters, loose food and trash debris, dirt, black matter, and grease were removed and new cleaning schedules were established for Daily, Weekly, and Monthly cleaning of the following items in question listed below All Items have be complicted by Dining Service Manager and Director of Maintance. Both will be inspecting daily, weekly, and monthly; 1) Interior of ice machine has been placed on a daily cleaning for all hinges/handles/ and other non-ice holding surfaces. Weekly removal of ice and interior full clean. 2) Flooring in door thresholds, corners, edges, between and under equipment have been placed on daily light clean, weekly inspection, with a monthly deep clean. 3) Ceiling, vents, and fire sprinklers have been cleaned and placed on a monthly cleaning schedule. 4) Fan cage in walk-in cooler has been cleaned and placed on a monthly cleaning schedule. 5) Interior of reach-in fridge and freezer has been cleaned and placed on a daily light cleaning, weekly inspection/cleaning and monthly deep cleaning/inspection. 6) Industrial can opener and housing has been cleaned and placed on a daily light clean, weekly deep clean, and monthly inspection/clean. 7) Interior of ovens have been cleaned and placed on a daily light clean, weekly deep clean, and monthing inspection. 8)Food processor base has been cleaned and placed on a daily light clean, weekly deep clean, and monthly inspection. 9) Interior of microwave including inside on the top has been cleaned and placed on a daily cleaning, weekly inspection/cleaning with a monthly deep cleaning schedule. 10) Industrial and countertop mixer have been cleaned and covered. With a daily light clean, weekly deep clean, and monthly inspection. 11) Utility carts have been replaced. 12) Wall behind and under washer has been cleaned and repaired and placed on a daily light clean and monthly deep clean and inspection. 13) Area on wall and floor under the sprayer in washing have been repaired/painted and  have been placed on weekly cleaning and monthly inspection. 14) Freezer and cooler floors under racks have been cleaned and placed on a daily inspection with a weekly light clean and monthly deep clean and inspection. B. The following areas in need of repair have been repaired or replaced: 1b.Caulking behind hand washing sink has been repaired. 2b. Caulking in ware washing area has been repaired. 3b. Large metal grate to grease trap by ware washer has been clean and painted. 4b. Fire sprinkler by hood has been repaired and cleaned to remove dust and debris. 5b. Small holes/open areas in walls under dish area and where pipes and/or electrical conduit have been repaired. C. Cutting boards have been replaced  . D. Industrial and countertop mixer have been covered when not in use. E. Pasteurized eggs have been purchased. F. Hairnets are in use. Staff have been coached on them. G. Scoops have been removed from bulk storage bins.

The findings of the kitchen inspection, conducted 7/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 7/12/23, conducted 9/12/23, 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 interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 4 sampled residents (#3) whose MARs and physician orders were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2019 with diagnoses including lymphedema. Review of the resident's 01/01/23 through 01/24/23 MAR, signed physician orders, progress notes, and temporary service plans, as well as staff interviews, identified the following: * The resident had an order for Furosemide (a diuretic) 20 mg twice daily, which s/he could self-administer without supervision. * On 12/20/22 the resident's physician requested the facility take over administering the resident's medications. * A temporary service plan dated 12/20/22 informed staff they would be administering the resident's medication, as the resident was "unable to manage" his/her medications "at this time." * The 01/01/23 through 01/24/23 MAR revealed staff had been documenting "U-SA" for both the 8:00 am and 8:00 pm doses of Furosemide, which indicated staff did not know if the resident had taken it because s/he self-administered the medication. In interview on 01/26/23, the surveyor advised Staff 3 (RCC) the Furosemide showed as self-administered on the MAR. Staff 3 stated the resident no longer self-administered medications and had not been receiving the diuretic as ordered. Staff 3 stated she would fax the resident's physician about the medication error and to request further instruction. On 01/26/23, the need to ensure medications were being administered as prescribed was discussed with Staff 1 (ED), Staff 2 (Health & Wellness Director/RN), and Staff 3. They acknowledged the medication error and indicated they would be increasing their MAR audits from monthly to weekly to better address potential concerns.

1.Immediate action was taken the day the violation was found. The Staff #3 RCC faxed the physician about the medication error and requested further instruction. 2. MAR audits will now be performed weekly vs. monthly as previously performed. 3. Correction are will be evaluated weekly. 4. Staff #2 RN and Staff #3 RCC will audit weekly and monitor for errors.

Based on interview and record review, it was determined the facility failed to consistently document all required elements on fire drill documentation, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records dated 08/22/22 through 01/24/23 were reviewed on 01/24/23. The following was identified: Fire drill documentation did not consistently include one or more of the following required elements: * Time of fire drill; * Location of simulated fire origin; * Escape route used; * Evacuation time-period needed; and * Evidence alternate routes were used during fire drills. The need to follow all OFC requirements pertaining to fire drills and documentation was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/RN), and Staff 3 (RCC) on 01/24/23. They acknowledged the findings. No additional information was provided.

1. Fire drills and fire & life safety training will now be recorded with complete information and documention. 2. Drill & training will now include the following: *Time of fire drill *Location of simulated fire origin *Escape route used *Evacuation time-period *Evidence that alternate routes were used during fire drills. 3. Monthly 4. Staff #1 ED will monitor and complete future drills and training.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to: Observations of the facility pathways and seating areas on 01/25/23 showed the following: * Multiple drop-offs of 2-4 inches were noted along pathway edges and resident personal patios. The need to ensure pathways around the facility, and around the residents' individual patios did not have potential tripping hazards was reviewed with Staff 1 (Executive Director) on 01/24/23. She acknowledged the findings and her plan to address the areas.

1.Multiple drop-offs of 2-4 inches were noted and those areas have been addressed by adding mulch to bring the receding pathway and resident personal patios up to required level. 2. Additional mulch has been ordered and weekly Staff #1 ED will walk the pathways to measure the levels and write work orders to have the additional mulch to be spread. 3. Once per week,the correction of additional mulch will be evaluated by Staff #1 ED. 4. Staff #1 ED will be respnsible to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: Observations of the facility on 01/24/23 through 01/25/23 showed the following areas in need of cleaning or repair: * Multiple walls on both floors had scrapes, chipped paint, drips or gouges; * Multiple dining room tables and chairs had large sections where the finish was significantly worn or gone. Chair arms and table legs had scrapes and gouges; * The cupboards, drawers and walls in the activity room had spills, stains and splatters. The refrigerator had spills inside the refrigerator, along the front grate and debris was on the bottom shelf; * The bathroom in the activity room had chipped counter top edges, missing and cracked laminate flooring and a large section of flooring that was pulling apart with a large gap between the two pieces of flooring; * Scrapes, dings and deep gouges were noted on doors, door frames or nearby walls at rooms 102, 103, 104, 113, 122, 123, 142, 143, 147, 151, 156, 157, 222, 241, 247, 251 and 252; * Window sills in the dining room, activity room and sitting room on the second floor had stains, debris, dead insects, bubbling and/or peeling paint or spills; * The main laundry room was noted to have multiple large scrapes across doors and walls, the small washing machine had dark accumulation at the back of the machine on top of and behind the lid and walls had deep gouges and scrapes with pieces of drywall or plaster missing. Cupboards and drawers had debris on the shelves and spills/stains to the fronts and insides; * The activity room, the area in front of the kitchen, the hallway alcove across from the kitchen, in front of the main laundry room, in front of the dining room and in front of rooms 223 and 224 had dark stains to the carpet of varying sizes; * Two brown banquet tables in the hallways had long scrapes and gouges across the table top and along the edges. The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) on 01/24/23. She acknowledged the findings.

1. All walls with scrapes, chipped paint, drips or gouges are being repaired. New dining room chairs, and tables will replace the old chairs and tables. Detailed cleaning of the activity room food area was performed immediately. In the Activity Area Bathroom a new countertop has been ordered. Flooring will also be replaced in the same bathroom. All scrapes, dings, and deep gouges on downstairs doors in process of being repaired. All window sills in common areas noted have been cleaned and repaired. Repairs and deep cleaning were performed in the main laundry room. Stains in carpet noted upstairs in front of #223 & #224 have been treated and removed, also stains in front of main laundry room and dining room have been treated and are in the process of being removed. New brown banquet tables have been ordered to replace the damaged. 2. The system was corrected by formal replacement of maintenance director. 3. The area(s) in need of correction will be evaluated weekly and then monthly thereafter. 4. Staff #1 ED will monitor corrections and work directly with maintenance director to see that the ongoing repair and replacement efforts are being completed.

The findings of the re-licensure survey, conducted 01/24/23  through  01/26/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 01/26/23, conducted 06/15/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.