Willamette Manor

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:
* Ceiling/Wall adjacent to grill/stove; * Exterior sides of oven; * Range top; * Exterior sides of fryer; * Removable hood vents; * Top of knife holder; * Floors in-between/behind equipment; * Open stainless steel shelving; * Stainless steel spice shelves; * Reach in coolers and freezers; * Movable Utility/baking rack; * Counter top mixer; * Plastic trays storing clean dishes; * Exterior of reach in cooler; * Black reach in cooler door handles; * Interior of drawers in dining room beverage station;* Plastic drawer station holding bread; and * Flooring in walk in freezer under/between metal racks.

1. All areas will be cleaned by 02/01/2025.
2. Daily and weekly cleaning checklists developed with Dining Service Manager weekly audits.
3. Dining Service Manager will audit cleaning checklists and audit areas on checklist and report to Executive Director weekly.
4. Executive Director.

b. The following areas needed repair:
* Holes around pipes in ceiling of condiment storage closet; * Holes around electrical conduit in kitchen area; and
* Industrial dish machine not consistently dispensing chemical sanitizer effectively/correctly.

1. a. Holes around pipes and electricl conduit were repaired/filled on 12/31/2024.
b. Industrial dish machine was serviced on 12/11/2024 where a leaking solenoid valve was replaced and intake screen was cleaned.
2. a. Maintenance team will survey area monthly for open holes in sheet rock on walls, flooring and ceiling.
b. Working with EcoLab on replacement of dish machine and any dispensing error will be reported to the Dining Service Manager or Executive Director immediately.
3. a. Monthly review by Maintenance team.
b. Dish machine will be checked twice daily to make sure it is operating correctly and errors will be immediately along with regular maintenance until machine is replaced.
4. Executive Director.

c. Multiple food items/packages/containers observed stored in reach in and walk in cooler without dates when opened/prepared. Multiple potentially hazardous food items found past seven days from preparation date. One item found multiple days past manufactures use by date.

1. All items were removed/discarded by 12/10/2024.
2. Dates including opened/prepared/expiration along with proper storage of items will be reviewed daily and included on daily cleaning checklist.
3. Dining Service Manager will audit cleaning checklist and audit areas on checklist and report to Executive Director weekly.
4. Executive Director


d. Multiple food items observed stored on the floor in the walk-in cooler, walk-in freezer and dry storage. The day of survey was not stock delivery day and Staff 2 (Dining Service Manager) acknowledged it should have been put away.

1. All items were picked up and stored properly by 12/10/2024.
2. Staff will verify stock and food items are off the floor and stored properly daily on daily cleaning checklist.
3. Dining Service Manager will audit cleaning checklist and audit areas on checklist and report to Executive Director weekly.
4. Executive Director

e. Dish machine was tested for adequate chlorine concentration levels. Machine was run multiple times yielding no parts per million (PPM) of sanitizer. Facility had no consistent process in place to monitor sanitation levels of dish machine to ensure dishes were sanitized per rule. The facility had test strips for chlorine but were noted to be expired in 2017. The facility had a log to monitor dishwasher wash temperatures but not sanitizer ppm and the last log entry was in October 2024.

1. Policy and procedure written, sanitation levels will be checked at least two times per shift. Chlorine strips were purchased on 12/10/2024 and service was completed 12/11/2024.
2. Dish machine station will be completed by 02/01/2025 equipped with chlorine strips, temperature and chlorine results log along with error tracking and steps to be taken when an error occurs including a call to EcoLab and Dining Service Manager and/or Executive Director.
3. Chlorine checks will be completed twice a shift and monitored daily and recorded on the log. Dining Service Manager will review daily.
4. Executive Director.

f. A red surface sanitation bucket was tested for sanitizer levels. No active PPM registered on the available sanitizer strips. Staff 2 validated that facility was not changing buckets every 2 hours as required to ensure effective sanitation of surfaces and was instead changing after each meal.

1. Policy and procedure written, sanitation buckets will be changed every 2 hours or when visibly soiled. Sanitation levels will be checked at least twice per shift and documented after each test.
2. Cleaning/sanitizing station will be completed by 02/01/2025 equiped with sanitizer testing strips, result log and laminated sign with time of last sanitizer change.
3. Sanitizing buckets will be changed every 2 hours or when visibly soiled and sanitizing levels will be checked at least twice a shift and monitored daily and recorded on the log. Dining Services Manager will review daily.
4. Executive Director

g. Kitchen staff were observed to handle ready to eat items with potentially contaminated gloves. This staff was observed to handle utensils, touch handles, and other potentially contaminated items or surfaces with their gloves and then touch ready to eat items. This staff was observed to not change gloves or wash hands when appropriate to ensure cross contamination did not occur. Staff was also observed to handle ready to eat lettuce with bare hands which is prohibited per rule.

1. Kitchen staff were re-trained on proper glove wear and hand washing on 12/17/2024.
2. PPE station will be completed by 02/01/2025 equipped with gloves, aprons, and other necessary PPE. Quick glove areas reassessed to harbor ease.
3. Dining Service Manager and leadership team will monitor glove use daily by observing and monitoring during food service.
4. Executive Director

h. Food contact surfaces of utensils were observed stored exposed to potential contamination. Dining room was observed to have pre-set utensils on the tables with the food contact surfaces uncovered exposing them to potential contamination.

1. All items have been properly stored.
2. Daily checklist developed. Staff will verify the proper storage of utensils both on dining tables and on dish rack daily.
3. Dining Service Manager will verify proper storage daily and weekly with audit.
4. Executive Director.

i. Facility had a census capacity greater than 17 residents and did not have a 3 compartment sink as required.

1. New 3 compartment sink ordered awaiting shipment date.
2. 3 compartement sink will be installed. Currently using sink and tub to equal 3 compartments.
3. Dining Service Manager will review weekly until new 3 compartment sink is in place.
4. Executive Director.

Concerns were identified in the following areas and the facility was provided with technical assistance:

C 295: Per Oregon Administrative Rule 333-019- 1011(1): Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases including possible food borne outbreaks and gastrointestinal outbreaks which includes having a food worker sick policy for exclusion as outlined in Oregon Food Sanitation Rules.

1. New policy and procedure written and implemented.
2. Quickguide posted throughout facility to help guide staff when they are sick. Infection prevention and food borne illness training will be completed every three months.
3. Will review any outbreaks and further training during quaility assurance quarterly meeting.
4. Executive Director.

Resident 1's service plan, dated 03/23/23 was not reflective or lacked clear direction to staff in the following areas: * Home Health services; and * Challenging behaviors/interventions.Provider's Plan of Correction:1. Service plan was updated to reflect behavior interventions and home health. 2. Service plan meetings will be completed weekly to review upcoming service plan reviews. A final review of the service plan will be completed by Community Nurse/Executive Director before closing and posting the service plan. 3. Quarterly by the Community Nurse/Executive Director unless there is a significant change of condition.4. The Community Nurse and Executive Director.Resident 4's service plan, dated 03/17/23 was not reflective or lacked directions to staff in the following area: * Use of C-PAP machine. Provider's Plan of Correction: 1. C-PAP was added to the care plan with the understanding the that resident/family at this time manages all operations, including cleaning and ordering of supplies for C-PAP. 2. Service plan meetings will be completed weekly to review upcoming service plan reviews. A final review of the service plan will be completed by Community Nurse/Executive Director before closing and posting the service plan.3. Quarterly by the Community Nurse/Executive Director unless there is a significant change of condition.4. The Community Nurse and Executive Director.Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and diabetes (Type 2). Observations of the resident, interviews with staff and review of the service plan dated 03/21/23, showed it was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Fall interventions; * Home health physical therapy; and * Use of a walker. Provider's Plan of Correction:1. Fall interventions, home health physical therapy, and the use of a walker have been added to the service plan. 2. Service plan meetings will be completed weekly to review upcoming service plan reviews. A final review of the service plan will be completed by Community Nurse/Executive Director before closing and posting the service plan. 3. Quarterly by the Community Nurse/Executive Director unless there is a significant change of condition.4. The Community Nurse and Executive Director.

Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and Diabetes Type 2. a. An incident report dated 04/19/23 documented "found resident on the floor in room barely responsive" and documented low blood pressure of 80/50 and low blood sugar of 75. b. The record documented multiple non-injury falls by Resident 1, with the following intervention developed: "remind to call for assistance". There was no documented evidence the intervention was evaluated for effectiveness following repeated falls. Provider's Plan of Correction:1. Change of condition service plan completed including documentation of interventions and/or instructions for staff regarding recent change of condition and repeated falls. 2. Incident follow-up will be completed within one week, checking with staff for the effectiveness of fall prevention and/or instructions. RCM will review any further incidents and possible changes in conditions with the Community Nurse and Executive Director at weekly service plan meetings. A final review will be completed by Community Nurse/Executive Director before closing and posting of the service plan.3. Quarterly by the Community Nurse/Executive Directoor/RCM unless there is a significant change of conditon or further falls. 4. Community Nurse, RCM and Executive Director.Resident 1 was admitted to the facility in 12/2015. The resident's service plan, dated 03/23/23, progress notes, dated 02/01/23 through 05/01/23, temporary service plans, and incident reports were reviewed. The resident experienced multiple short-term changes without documentation of needed interventions or monitoring of existing interventions for the following areas: * Falls; and * Behaviors. a. The records documented three falls by Resident 1, with the following interventions developed: * Keep pathways clear; * Non-slip shoes; * Grab bars in bathroom; * Call for assistance when toileting; and * Limit items on walker. There was no documented evidence these interventions were evaluated for effectiveness, following repeated falls. b. Resident 1's service plan documented the resident "would have loud outbursts and shake his/her fist at you". Progress notes stated the resident had become "so disruptive at times, that [he/she] had been asked to leave the activity room". There was no documented evidence interventions had been developed for these behaviors. Provider's Plan of Correction:1. Service plan was updated to reflect interventions for falls, and behaviors. The service plan also includes behavioralist interventions and suggestions per their report.2. Incident follow-up will be completed within one week, checking with staff for the effectiveness of fall prevention and/or instructions. RCM will review any further incidents and possible changes in condition with the Community Nurse and Executive Director at weekly service plan meetings. A final review will be completed by Community Nurse/Executive Director before closing and posting the service plan.3. Quarterly by the Community Nurse/Executive Director/RCM unless there is a significant change of condition or further falls. 4. Community Nurse, RCM, and Executive Director.

Resident 1 was admitted to the facility in 12/2015. Review of Resident 1's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies: The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 500 mg and tramadol 50mg. There were no instructions for the sequential order of administration. Provider's Plan of Correction:1. Parameters have been entered for PRN pain medications for all necessary MARs.2. During our three-check medication order process the Community Nurse and RCM will review any PRN medication orders to make sure parameters are requested and put in place.3. Quarterly by the Community Nurse, RCM, and/or Executive Director.4. The Community Nurse, RCM, and Executive Director.Resident 4 was admitted to the facility in 02/2023. Review of Resident 4's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies: The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 325 mg and tramadol 50 mg. There were no instructions for the sequential order of administration.Provider's Plan of Correction:1. Parameters have been entered for PRN pain medications for all necessary MARs.2. During our three-check medication order process the Community Nurse and RCM will review any PRN medication orders to make sure parameters are requested and put in place.3. Quarterly by the Community Nurse, RCM, and/or Executive Director.4. The Community Nurse, RCM, and Executive DirectorResident 3 was admitted to the facility in 06/2022 with diagnoses including diabetes (Type 2) and chronic kidney disease (Stage 3). Review of Resident 3's MAR, dated 04/01/23 through 04/30/23 identified the following deficiencies: * On 04/02/23 the MAR lacked documentation of whether the medications vitamin D 50 MCG, Pantoprazole Sodium 1 tab, adult multivitamin 1 tab, metoprolol succinate ER 50 mg, Saccharomyces boulardii 250 mg, and gabapentin 100 mg were administered; and * The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen and tramadol. There were no instructions for the sequential order of administration. In interview on 05/03/23 Staff 2 (RN) stated she was aware of a computer issue on that day, the medications had been given as ordered, and should have been entered into the electronic MAR when the issue was resolved. Provider's Plan of Correction:1. Parameters have been entered for PRN pain medications for all necessary MARs. Daily audits (M-F) will now be completed to review accuarcy of the MAR.2. During our three-check medication order process the Community Nurse and RCM will review any PRN medication orders to make sure parameters are requested and put in place. RCM will audit to make sure the daily MAR audits are being completed. 3. RCM Audit log will be turned in weekly to the Community Nurse.4. The Community Nurse, RCM and Executive Director.

The facility grounds were toured with Staff 5 (Maintenance Director) on 05/02/23. The following items were in need of cleaning or repair: * Wood railing of outdoor deck near kitchen was warped, with cracked and peeling paint; * Dark stains were present on multiple carpet areas throughout the building. Provider's Plan of Correction:1. Wood railing will be replaced and painted. The carpet will be replaced in some areas and cleaned professionally in other areas per our professional carpet cleaning company's recommendations.2. Our maintenance team will complete a yearly stain protective/re-painting to the back deck including an inspection. Professional carpet cleaning is now scheduled quarterly. 3. Quarterly with our Quality Assurance Meeting.4. Maintenance Director and Executive Director.

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:1. *Dining room beverage area, the shelf will be removed and the legs will be replaced with stainless steel by 03/15/2023*Kitchen drains will be cleaned by 03/15/2023*Interior and exterior of metal drawers will be emptied and cleaned appropriately by 03/15/2023*Celiling fire sprinklers and vents have been cleaned as of 02/09/2023 *Interior and exterior of microwave, the microwave was replaced on 02/08/2023*Stove/grill/oven knobs, doors, interior and exterior will be deep by cleaned 02/28/2023*Metal table and the surrounding area beside the grill/stove, the table has been removed and the area will be deep cleaned by 03/15/2023*Hood above the grill/stove with a large accumulation of dirt/grease debris on removable vent covers, vent covers were deep cleaned on 01/27/2023*Open shelving throughout the kitchen will be deep cleaned or replaced by 03/15/2023*Industrial mixer was removed from service on 02/09/2023*Large can opener housing was been deep cleaned on 01/27/2023*Fans by prep/cooking/serving area have been removed along with the freestanding air conditioner on 02/10/2023 and the area will be deep cleaned by 03/15/2023*Light fixtures and areas of the ceiling, all light fixtures have either been repaired and cleaned or replaced as of 02/10/2023, the ceiling will be deep cleaned and painted by 03/15/2023*Window seal will be deep cleaned by 03/15/2023*Pipes and light/electrical outlet covers behind the stove will be deep cleaned by 03/15/2023*Interior and exterior of plastic drawers throughout the kitchen will be removed as of 03/15/2023*Exterior of the blender has been deep cleaned as of 02/10/2023*Exterior of trash cans with a heavy build-up of dirt/debris, cans will be replaced with metal easy clean cans by 03/15/2023*Reach-in refrigerators and freezer handles, exterior and interior, handles have been replaced on reach-in as of 02/09/2023 and both appliances will be deep cleaned by 03/15/2023*Top of the ice machine with a thick layer of dust, has been deep cleaned as of 02/10/2023*Plate warmer interior and exterior will be deep cleaned by 03/15/2023*Top of the service area across from the stove/grill will be decluttered and deep cleaned by 03/15/20232. Awaiting quotes for an outside contracted one-time deep cleaning of the area and a weekly cleaning checklist will be implemented with kitchen staff in coordination with housekeeping to complete the weekly deep cleaning of mentioned areas.3. Weekly by Dietary Manager and monthly with Dietary Manager and Administrator4. Administratorb. Areas needing repair.1. *Appointment scheduled with an HVAC company to review the Dishwasher hood vent as of 02/10/2023*All light fixtures have been either replaced or fixed as of 02/10/2023*Industrial and countertop mixers have been removed from service as of 02/09/2023.*Metal shelves will all be replaced or repaired, and all wood shelves in the kitchen will be removed and replaced with stainless steel by 03/15/2023*Cooling fans in the walk-in will be cleaned by Maintenance by 03/15/2023*Cabinets and countertop by and near the beverage station in dining room with damage, area will be cleaned and repaired by 03/15/2023*Open shelving and countertop of steam table with missing or damaged to shelfs causing an uncleanable surface, countertop and shelving will be repaired/replaced by 02/18/2023*Vents/fire sprinklers in kitchen with dust and dirt build-up will be cleaned be deep cleaned by 03/15/2023 *Snap pest traps have been removed as of 01/27/2023*Shelving in the interior refrigerator have been replaced as of 02/10/2023*Missing outlet cover in dry goods storage was replaced on 01/27/2023*Gaps in sprinkler mounts will be repaired by 03/15/2023*Coffee closet with multiple damaged shelves and place in the floor with laminate floor missing, flooring, and shelving replaced or repaired as of 02/10/2023c. Food items in refrigerators or freezers not covered/sealed to prevent potential contamination, foods items will be covered/sealed per OHA Food Sanitation Rules as reviewed on 02/14/2023 with dietary staff and containers for storage will be replaced if needed by 03/15/2023d. Multiple cutting boards were found to be heavily scored or stained, cutting boards have been disposed of and new ones have been put in service as of 02/08/2023e. Salad dressings not labeled with a use-by date and multiple potentially hazardous food items past their used-by dates, food items will now be labeled with used-by-day using sticker including all opened or partially used items and dates will be reviewed daily, OHA Food Sanitation Rules discussed with dietary staff on 02/14/2023f. Kitchen staff storing personal food items in the walk-in cooler, concern was discussed in a recent staff meeting on 02/14/2023, staff understand that personal food items can't be kept in kitchen 2. Kitchen staff will notify Dietary Manager when they notice areas needing repair and Dietary Manager will notify Maintenance by completing a "Request for Maintenance" form. Items in refrigerators and freezers will be audited weekly for used-by dates and to review if food is covered/sealed by Dietary Manager. The Dietary Manager will also inspect cutting boards monthly during the walk through. 3. All areas will be inspected monthly by Dietary Manager, Maintenance, and Administrator.4. Administrator