Touchmark at Mount Bachelor Village.

“Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 01/30/26 at 11:30am to 1:45pm, the facility kitchen was observed to need cleaning and repair in the following areas: Areas in need of cleaning and/or repair: *Several areas on floor throughout kitchen-cracks, unsealed cement, non-cleanable surface; *Wall behind dishwasher-black, deteriorated caulk, non-sealed surface; and *Ceiling in dish room- flaking, water / heat damaged; and *Ware washing Equipment for Hot Water Sanitation- below minimum temperature requirements. During an observation on 01/30/26 at approximately 12:30pm, Staff 3 (Sous Chef) demonstrated the dish machine did not meet temperature requirements. Staff 1 (PIC/Executive Chef) reported several days of temperature recordings below requirements. Surveyor observed the kitchen did not have a three compartment sink for manual dishwashing. Staff planned to utilize the dish machine in the adjacent independent kitchen while repair was made. Surveyor observed the dish washer in the independent kitchen was meeting hot water temperature requirements. The areas of concern were observed and/or discussed with Staff 1 (PIC/Executive Chef), Staff 2 (Admin/Health Services Director) and Staff 3 (Sous Chef). Staff acknowledged the findings at approximately 1:45pm on 01/30/26. Our Building Services will be repairing and resealing the areas identified. Grind down porous areas, paint and reseal to achieve a non-porous, cleanable and within regulations flooring. Caulking has been ordered and once it has arrived the old caulking will be removed and then will be resealed by our Building Services team. Panels have been ordered to replace the damaged ones and once they have arrived the damaged ones will be replaced with the new ones by the Building Services team. Repairman has come in and reconnected the water lines to the heat booster and the machine has been consistently hitting the required tempuratures above 180 degrees F. PIC is providing a Temp Log to be able to ensure daily compliance with this regulation. And three large containers that will be dedicated to provide a three-compartment sink setup as needed have been ordered. To ensure that the recent violations do not reoccur, the Building Services Director and the PIC for the kitchen will review kitchen environment on a quarterly basis. 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:”

“Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Refer to C240. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“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 unannounced complaint investigation conducted 03/31/25.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint. 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 unannounced complaint investigation conducted 03/31/25.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.”

“The findings of the re-licensure survey, conducted 07/29/24 through 07/31/24, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. 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 re-licensure survey, conducted 07/29/24 through 07/31/24, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. 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 revisit to the re-licensure survey of 07/31/24, conducted on 09/20/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. The findings of the revisit to the re-licensure survey of 07/31/24, conducted on 09/20/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.”

“Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records from 12/2023 through 06/2024 were reviewed with Staff 1 (Health Services Director) on 07/30/24, and the following was identified: a. The facility lacked documentation fire drills were being conducted on alternating months. b. For fire drills which were completed between 12/2023 and 06/2024, the following required elements were not documented: * Escape route used; and * Evidence alternate routes were used during the fire drills. c. There was no documented evidence fire and life safety instruction for staff had been on alternate months. The need to provide fire and life safety instruction to staff and conduct unannounced fire drills on alternate months and document all required elements was discussed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings. Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records from 12/2023 through 06/2024 were reviewed with Staff 1 (Health Services Director) on 07/30/24, and the following was identified: a. The facility lacked documentation fire drills were being conducted on alternating months. b. For fire drills which were completed between 12/2023 and 06/2024, the following required elements were not documented: * Escape route used; and * Evidence alternate routes were used during the fire drills. c. There was no documented evidence fire and life safety instruction for staff had been on alternate months. The need to provide fire and life safety instruction to staff and conduct unannounced fire drills on alternate months and document all required elements was discussed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings. What actions will be taken to correct the rule violation? Alternating months of Fire and Life Safety training are Relias videos.  This has been reviewed and confirmed to be corrected for the remainder of the year and moving forward into 2025. The unannounced fired drills will continue to be scheduled and conducted every other month following calendar in the Fire and Life Safety Binder and calendar appointments to those who conduct and oversee these drills. . How will the system be corrected so this violation will not happen again? The Health Services Director/Administrator will confirm that the correct Fire and Life Safety videos are correctly populated when new hires are brought on for alternating months of active drills.   The correct form for fire drills will be used for all active fire drills on appropriate months and will have a detailed description of the route of evacuation and will ensure compliance of alternating those evacuation routes correctly documented. How often will the area needing correction be evaluated? This will be done at time of hire, ensuring correct Relias training templates, and on alternating months of the active fire drills ensuring correct documentation. Who on your staff will be responsible to see that the corrections are completed/monitored? The Health Services Director/Administrator What actions will be taken to correct the rule violation? Alternating months of Fire and Life Safety training are Relias videos.  This has been reviewed and confirmed to be corrected for the remainder of the year and moving forward into 2025. The unannounced fired drills will continue to be scheduled and conducted every other month following calendar in the Fire and Life Safety Binder and calendar appointments to those who conduct and oversee these drills. . How will the system be corrected so this violation will not happen again? The Health Services Director/Administrator will confirm that the correct Fire and Life Safety videos are correctly populated when new hires are brought on for alternating months of active drills.   The correct form for fire drills will be used for all active fire drills on appropriate months and will have a detailed description of the route of evacuation and will ensure compliance of alternating those evacuation routes correctly documented. How often will the area needing correction be evaluated? This will be done at time of hire, ensuring correct Relias training templates, and on alternating months of the active fire drills ensuring correct documentation. Who on your staff will be responsible to see that the corrections are completed/monitored? The Health Services Director/Administrator There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C420. Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C420. ** See previous POC for tag C420 ** See previous POC for tag C420 There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure 3 of 4 caregiving staff (#s 6, 8, and 13) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (Health Services Director) on 07/30/24 and 07/31/24. There was no documented evidence Staff 6 (CG), hired 06/04/24, Staff 8 (MA), hired 06/12/24, and Staff 13 (CG), hired 03/11/24, had demonstrated competency all job duties including: * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure 3 of 4 caregiving staff (#s 6, 8, and 13) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (Health Services Director) on 07/30/24 and 07/31/24. There was no documented evidence Staff 6 (CG), hired 06/04/24, Staff 8 (MA), hired 06/12/24, and Staff 13 (CG), hired 03/11/24, had demonstrated competency all job duties including: * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 on 07/30/24 and 07/31/24. He acknowledged the findings. What actions will be taken to correct the rule violation? Checklist has been updated to cover all the required training competencies, including role of service plan, Relias videos covering providing assistance, changes associated with normal aging, Identifying, documentation and reporting changes of condition and Conditions that require assessment, treatment, observation and reporting have been confirmed to be correctly templated with state approved trainings.  Additionally, all team members have completed any missing training to come into compliance with the required training in the first 30 days. How will the system be corrected so this violation will not happen again? Moving forward, no team members will be allowed to work without the Health Services Director/Administrator reviewing that all training and documentation of training is complete before working the floor solo. How often will the area needing correction be evaluated? Upon new hire and again within the 30 days of start date. Who on your staff will be responsible to see that the corrections are completed/monitored? The Health Services Director/Administrator. What actions will be taken to correct the rule violation? Checklist has been updated to cover all the required training competencies, including role of service plan, Relias videos covering providing assistance, changes associated with normal aging, Identifying, documentation and reporting changes of condition and Conditions that require assessment, treatment, observation and reporting have been confirmed to be correctly templated with state approved trainings.  Additionally, all team members have completed any missing training to come into compliance with the required training in the first 30 days. How will the system be corrected so this violation will not happen again? Moving forward, no team members will be allowed to work without the Health Services Director/Administrator reviewing that all training and documentation of training is complete before working the floor solo. How often will the area needing correction be evaluated? Upon new hire and again within the 30 days of start date. Who on your staff will be responsible to see that the corrections are completed/monitored? The Health Services Director/Administrator. There are no detail notes for this visit.”

“The findings of the kitchen inspection, conducted 02/27/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 02/27/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.”