Farmington Square Gresham.

“Based on interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access their unit for multiple sampled and unsampled residents. Findings include, but are not limited to: During the re-licensure survey, dated 03/17/25 through 03/20/25, resident service plans were reviewed and interviews with residents, family members, and staff were completed. Interviews with Resident 2 and 7 confirmed they were not provided keys to their apartments. Follow-up interviews with Resident 2 and 5’s family members confirmed no key was provided to the resident or the resident’s family. On 03/20/25 at 8:38 am, Resident 2 stated s/he wanted a key for his/her apartment. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1, Staff 2 (General Manager), Staff 4 (RN), Staff 7 (LPN), Staff 8 (Wellness Director), and Staff 40 (Operations Specialist) on 03/20/25 at 11:18 am. They acknowledged the findings.”

“Based on observation and interview, the facility failed to post the LGBTQIA2S+ Rights and Protections and the LGBTQIA2S+ Nondiscrimination Notice. Findings include, but are not limited to: Refer to C152 Refer to C 152. OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by:”

“Based on observation, 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: C 152, C 200, C 295, C 420, C 422, C 510, C 513. Refer to C152, C 200, C 295, C 420, C 422, C 510, C513. 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:”

“based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents who resided in the memory care cottages had individually identified residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to: The facility’s three memory care cottages, Crown, Diamond and Emerald were toured on 03/17/25. Multiple resident rooms in each cottage lacked any individualized identification to assist residents in recognizing their room. On 3/17/25 at 11:40 am, an unsampled resident was observed going into multiple resident rooms and was asking caregivers where his/her room was. Upon further observation, the resident’s room lacked an individual identifier to assist the resident in recognizing his/her room. The need to ensure each resident room was individually identified to assist residents in recognizing their room was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure the required postings were in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times. Findings include, but are not limited to: The facility was toured on 03/17/25, and it consisted of five separate and distinct cottages. The following postings were not posted in each of the cottages as required: * Copy of most recent re-licensure survey, including all revisits and POC; * The Ombudsman Notification Poster; * The LGBTQIA2S+ Rights and Protections; and * The LGBTQIA2S+ Nondiscrimination Notice. The need to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure medical and other records were kept confidential. Findings include, but are not limited to: During the relicensure survey from 03/17/25 through 03/20/25 observations were made of a printer and fax machine used to communicate resident health information to and from the facility located in a resident use laundry room. Multiple unsampled resident's confidential information was observed on the fax machine and/or printer during the survey. On 03/17/25, observations of medical and/or other records were left on a counter next to the fax machine while two residents were in the laundry room. The documents were gathered and given to Staff 2 (General Manager) who stated she would discuss the concern with Staff 1 (ED). On 03/19/25 and 03/20/25 additional documents were observed on the printer and/or fax machine throughout each day. The findings were reviewed with Staff 1 and Staff 2 on 03/20/25 at approximately 11:54 am. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to designate an individual to be the facility’s “Infection Control Specialist”, and to establish and maintain infection preventions and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 resident (#7), whose records were reviewed. Findings include, but are not limited to: a. In an interview on 03/20/25, Staff 1 (ED) acknowledged the facility did not designate an individual to be the facility’s “Infection Control Specialist” responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. b. Resident 7 was admitted to the facility in 03/2023 with diagnoses including dementia, aphasia, dysphagia, retention of urine and multiple sclerosis. During the acuity interview on 03/17/24, Resident 7 was reported to require a high degree of care, including a soft mechanical texture diet requiring assistance with meals. During the survey from 03/17/25 through 03/20/25, the surveyor obtained permission and observed the facility staff provide personal care and feeding to Resident 7. The resident was noted to require total care assistance from staff. On multiple instances, direct care staff donned gloves without first performing hand hygiene, did not change single use gloves between tasks, and performed feeding without wearing a protective barrier over clothing to prevent the potential for cross contamination. On 03/17/25 at 12:49 pm, Staff 31 (MT) was observed to drop a tube of prescription cream on the floor, the MT proceeded to pick up and administer the medication to the resident without changing gloves prior to administering the cream. c. On 03/17/25 and 03/18/25 during lunch service, the survey team observed staff transporting meals within Barlow cottage from the kitchenette to residents’ rooms without proper plate covering. Additionally, the survey team observed an uncovered tray of brownies that were taken into a resident’s room. d. Observations of lunch service on 03/18/25 and 03/19/25, revealed multiple direct care staff in Diamond cottage served food and provided direct feeding to residents having donned gloves without first performing hand hygiene and without donning a protective barrier over potentially contaminated clothing. The need to ensure the facility designated an individual to be the facility’s “Infection Control Specialist” and to establish and maintain effective infection prevention and control protocols was reviewed with Staff 1, Staff 2 (General Manager), Staff 4 (RN), Staff 7 (LPN), Staff 8 (Wellness Director), Staff 10 (Wellness Director), and Staff 40 (Operations Specialist) on 03/20/25 at 11:04 am and again at 11:54 am. They acknowledged the findings. infection control, designated person, handwashing and glove use, covering food, aprons designated person in place, additional training for care staff and dining”

“Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 09/2024 through 02/2025 identified the following: * The facility was not evacuating residents from the simulated fire area; therefore, there was no documentation of: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. * Additionally, the facility failed to document the staff members on duty and participating in the drill in two of the three drills completed. On 03/19/25 at 12:00 pm, Staff 6 (Maintenance Director), confirmed residents were not evacuated or relocated during fire drills. On 03/19/25 at 12:00 pm, the need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 1 (ED), Staff 2 (General Manager), Staff 3 (Business Office Manager), Staff 6 and Staff 40 (Operations Specialist). They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 09/2024 through 02/2025 revealed no documented evidence of annual fire safety re-instruction for residents. On 03/19/25 at 12:00 pm, Staff 1 (ED) confirmed the facility did not have a system for re-instructing residents, at least annually, on fire and life safety expectations. On 03/19/25 at 12:00 pm, the need to re-instruct residents, at least annually, on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire per the OFC requirements was discussed with Staff 1, Staff 2 (General Manager), Staff 3 (Business Office Manager), Staff 6 (Maintenance Director) and Staff 40 (Operations Specialist). They acknowledged the findings. 1.The Community will complete the Fire and Life Safety Annual Resident Safety Training for all Residents. 2. The Maintenance Director and Executive Director will receive additional training on Resident Safety Training. 3. Fire and Life Safety Annual Resident Safety Training Documentation will be reviewed annualy per the QA - Maintenance Review Schedule. 4. The Executive Director will be responsible for ensuring compliance. OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the RCF common use areas, entrance and exit ways were made of hard, smooth material, were accessible and maintained in good repair and all chemicals and other toxic materials were safely stored in a locked storage. Findings include, but are not limited to: During a tour of the facility from 03/17/25 through 03/19/25. The facility consisted of five separate and distinct cottages and the following was identified: a. Three of the cottages had interior courtyards, Astor, Barlow, and Crown. Astor and Barlow had patios attached to some resident rooms. All the courtyards and patios did not have a threshold that was accessible for residents who used wheelchairs or walkers. Additionally, the wooden ramp access to the back courtyard in the Crown cottage was not in good repair. During an interview on 03/18/25 at 1:38 pm, Resident 1 reported s/he had difficulty getting over the front entrance threshold of the Barlow cottage in his/her wheelchair. b. Cleaning chemicals and disinfectants were found unlocked in housekeeping closets in the Astor cottage and Crown memory care cottage. The closets were easily accessible to residents. Upon reinspection on 03/18/25 and 03/19/25, the housekeeping closet was found unlocked in Astor. The need to ensure all exterior pathways and accesses to the RCF common use areas, entrance and exit ways were made of hard, smooth material, were accessible and maintained in good repair and all chemicals and other toxic materials were safely stored in a locked storage was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure when an electronic code must be entered to use an exit door, it was clearly posted for residents, visitors and staff use and all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 03/17/25. The facility consisted of five separate and distinct cottages, two ALF and three MCC units. The following was identified: a. The main entrance to Barlow, the enhanced ALF, had a code for entry and it was not clearly posted for resident use. During survey, it was identified not all residents knew the code. b. The following areas were in need of repair: * In Astor, the sink in the staff/visitor bathroom was separating from the wall with a large crack present; * In Barlow, the mirror in the resident’s shower room was broken, and the inside laundry room door was lacking trim; * In Crown, the call light cord was missing, and the shower head holder was broken in the resident’s main shower room; and * In Crown, resident room 44, the shower head holder and window blinds were broken; and * In Diamond, the paint was lifting off the wall above the door trim near the common area. The lack of electronic code to an exit door being clearly posted for residents, visitors and staff use and ensuring all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure residents' rights of privacy and dignity for multiple sampled and unsampled residents whose medical information was maintained in the facility. Findings include, but are not limited to: Refer to C 200. Refer to C 200. OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure the setting optimized, but did not regiment, individual initiative, autonomy, self-direction and independence in making life choices for multiple sampled and unsampled residents who resided in the Barlow cottage. Findings include but are not limited to: Refer to C 513a. Refer to C 513a. OAR411-004-0020(1)(e) Optimize Settings: Independence, Activities (1) Residential and non-residential HCB settings must have all of the following qualities: (e) The setting optimizes, but does not regiment, individual initiative, autonomy, self-direction and independence in making life choices including, but not limited to: daily activities, physical environment, and with whom the individual chooses to interact. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure the setting was physically accessible to individuals. Findings include, but are not limited to: Refer to C 510a. Refer to C 510a. OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure each individual resident had privacy in his/her own unit for multiple sampled and unsampled residents who resided in the MCC cottages. Findings include, but are not limited to: During the re-licensure survey, dated 03/17/25 through 03/20/25, the environment was toured and interviews with staff and residents were completed. The following were revealed: a. Multiple residents who resided in the Diamond and Emerald cottages shared an apartment. The bathrooms in the shared apartments were observed to lack a locking mechanism that would ensure privacy to the resident in his/her own unit. On 03/19/25 at 10:00 am, Staff 40 (Operations Specialist) confirmed the bathroom doors of shared units did not have the ability to be locked. b. The doors of resident apartments in the Crown, Diamond, and Emerald cottages were observed to have lever-type handles. These handles had a keyed locking mechanism on the exterior of the door; however, the interior handle had no mechanism that would allow a resident to lock the door from inside the room to ensure privacy. On 03/20/25, Staff 14 (MT/CG), Staff 20 (CG), and Staff 21 (MT) confirmed the doors in Crown, Diamond, and Emerald cannot be locked from the inside. The need to ensure residents were provided with individual privacy in their own unit was discussed with Staff 1 (ED), Staff 2 (General Manager), Staff 4 (RN), Staff 7 (LPN), Staff 8 (Wellness Director), and Staff 40 on 03/20/25 at 11:18 am. They 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 02/20/25.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health HS: Hours of sleep LPN: Licensed Practical Nurse MT:            Medication Technician or Med Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse SP: Service plan SPT: Service Planning Team TAR: Treatment Administration Record 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 02/20/25.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health HS: Hours of sleep LPN: Licensed Practical Nurse MT:            Medication Technician or Med Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse SP: Service plan SPT: Service Planning Team TAR: Treatment Administration Record”

“Based on interview and record review, conducted during a site visit on 02/20/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled Resident (# 4) was substantiated. Findings include, but are not limited to: Resident 4's service plan, dated 02/01/24, indicated Resident 4 required one to two medication passes per day and the facility was responsible for the service. Resident 4's Incident Report, dated 04/16/24 indicated Resident 4 was administered Resident 3's morning medications. Resident 4's Progress notes, dated 04/01/24 through 04/30/24, indicated s/he was placed on alert charting for the medication error and did not have an adverse reaction to the incorrect medication. The facility's self-report, dated 04/16/24, indicated Resident 4 had received his/her roommate's morning medications by mistake. Staff 1 (Executive Director) stated s/he recalled the medication error and Resident 4 received his/her roommate's medication by accident. Staff 1 further stated the staff member who administered the incorrect medication no longer works at the facility. Resident 4 was no longer in the building and could not be observed or interviewed. It was determined the facility's failure to carry out medication and treatment orders as prescribed for Resident 4. The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (General Manager). The facility's plan of correction: The facility provided the staff member additional training on proper medication administration and how to avoid medication errors in the future. The staff member who administered the incorrect medication no longer works at the facility. Based on interview and record review, conducted during a site visit on 02/20/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 1) was substantiated. Findings include, but are not limited to: Resident 1's service plan, dated 06/30/24, indicated Resident 1 required three to four medication passes per day and the facility was responsible for the service. The facility's self-report, dated 07/09/24, indicated Resident 1 received his/her roommate's medications. Resident 1's primary care physician ordered Resident 1 to be sent to the hospital for monitoring. Resident 1's progress notes, dated 07/01/24 through 07/31/24, indicated Resident 1 was put on alert charting to monitor for any adverse reactions due to the medication error after s/he returned from the hospital. Staff 2 (Regional Manager) stated s/he was the former Executive Director of this facility and remembered the medication error with Resident 1. A staff member had given Resident 1 his/her roommate's medications. It was determined the facility's failure to carry out medication and treatment orders as prescribed for Resident 1 was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2. The facility's plan of correction: The facility provided the staff member additional training on proper medication administration. The facility implemented for staff to take the resident's medication box with them when administering medications. The medication box has a photo of the resident on it. If the resident does not have a photo uploaded to their system, staff are not allowed to pre-pop or pour a resident's medication and must pop it right after verifying the resident's identity and administer the medication. Based on interview and record review, conducted during a site visit on 02/20/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled Resident (# 4) was substantiated. Findings include, but are not limited to: Resident 4's service plan, dated 02/01/24, indicated Resident 4 required one to two medication passes per day and the facility was responsible for the service. Resident 4's Incident Report, dated 04/16/24 indicated Resident 4 was administered Resident 3's morning medications. Resident 4's Progress notes, dated 04/01/24 through 04/30/24, indicated s/he was placed on alert charting for the medication error and did not have an adverse reaction to the incorrect medication. The facility's self-report, dated 04/16/24, indicated Resident 4 had received his/her roommate's morning medications by mistake. Staff 1 (Executive Director) stated s/he recalled the medication error and Resident 4 received his/her roommate's medication by accident. Staff 1 further stated the staff member who administered the incorrect medication no longer works at the facility. Resident 4 was no longer in the building and could not be observed or interviewed. It was determined the facility's failure to carry out medication and treatment orders as prescribed for Resident 4. The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (General Manager). The facility's plan of correction: The facility provided the staff member additional training on proper medication administration and how to avoid medication errors in the future. The staff member who administered the incorrect medication no longer works at the facility. Based on interview and record review, conducted during a site visit on 02/20/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 1) was substantiated. Findings include, but are not limited to: Resident 1's service plan, dated 06/30/24, indicated Resident 1 required three to four medication passes per day and the facility was responsible for the service. The facility's self-report, dated 07/09/24, indicated Resident 1 received his/her roommate's medications. Resident 1's primary care physician ordered Resident 1 to be sent to the hospital for monitoring. Resident 1's progress notes, dated 07/01/24 through 07/31/24, indicated Resident 1 was put on alert charting to monitor for any adverse reactions due to the medication error after s/he returned from the hospital. Staff 2 (Regional Manager) stated s/he was the former Executive Director of this facility and remembered the medication error with Resident 1. A staff member had given Resident 1 his/her roommate's medications. It was determined the facility's failure to carry out medication and treatment orders as prescribed for Resident 1 was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2. The facility's plan of correction: The facility provided the staff member additional training on proper medication administration. The facility implemented for staff to take the resident's medication box with them when administering medications. The medication box has a photo of the resident on it. If the resident does not have a photo uploaded to their system, staff are not allowed to pre-pop or pour a resident's medication and must pop it right after verifying the resident's identity and administer the medication.”

“Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled Residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and St”

“Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled Residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and St”

“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 OARs 333-150-0000. Findings include, but are not limited to: On 01/15/25 at 10:30 am, the facility kitchenettes (Astor, Barlow, ,Crown and, Diamond) dishwashers were observed with Staff 1 (Director of Dining Services) and it was determined the facility did not have a system in place to check the temperatures and chlorine levels routinely to ensure appropriate temperatures and chlorine levels. Surveyor and Staff 1 checked temperatures in each kitchenette, all met minimum temperature of 120 degrees, except in Crown (90 to 115 degrees). Chlorine levels were also checked in each kitchenette, all met minimum levels. The areas of concern were observed and discussed with Staff 1 and discussed with Staff 2 (Executive Director) and Staff 3 (Regional Director of Operations) on 01/15/25. The findings were acknowledged.”

“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 C 240. 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:”

“Based on interview and record review, conducted during a site visit on 01/02/24, it was confirmed that the facility failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training for 3 of 3 sampled staff (#4, 5 & 6) staff whose training records were reviewed. Findings include, but are not limited to the following: In an interview on 01/02/24, Staff 1 (Administrator) stated staff complete dementia training as part of the facility's orientation program and the facility uses a Memory Care Orientation and Training Checklist. A review of Staff 4 (Med Tech), Staff 5 (Med Tech) and Staff 6s' (Caregiver) training records indicated 1 of 3 (# 6) staff did not have a completed Memory Care Orientation and Training Checklists. Training records for 3 of 3 staff lacked training in the following areas: * Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms; * Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: · Identify and address pain; · Provide food and fluids; · Prevent wandering and elopement; and · Use a person-centered approach. In an email correspondence on 01/11/24, Staff 1 stated the facility primarily uses Relias for pre-orientation memory care training and the checklist is done in addition to the online training. The facility failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 2 (Life Enrichment Director). Facility Verbal Plan of Correction: Administrator and life enrichment director will complete an audit of staff training records to determine if other staff are missing pre-service dementia training and review OAR to ensure staff and facility is complying with pre-service training requirements. Based on interview and record review, conducted during a site visit on 01/02/24, it was confirmed that the facility failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training for 3 of 3 sampled staff (#4, 5 & 6) staff whose training records were reviewed. Findings include, but are not limited to the following: In an interview on 01/02/24, Staff 1 (Administrator) stated staff complete dementia training as part of the facility's orientation program and the facility uses a Memory Care Orientation and Training Checklist. A review of Staff 4 (Med Tech), Staff 5 (Med Tech) and Staff 6s' (Caregiver) training records indicated 1 of 3 (# 6) staff did not have a completed Memory Care Orientation and Training Checklists. Training records for 3 of 3 staff lacked training in the following areas: * Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms; * Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: · Identify and address pain; · Provide food and fluids; · Prevent wandering and elopement; and · Use a person-centered approach. In an email correspondence on 01/11/24, Staff 1 stated the facility primarily uses Relias for pre-orientation memory care training and the checklist is done in addition to the online training. The facility failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 2 (Life Enrichment Director). Facility Verbal Plan of Correction: Administrator and life enrichment director will complete an audit of staff training records to determine if other staff are missing pre-service dementia training and review OAR to ensure staff and facility is complying with pre-service training requirements.”

“Based on observation and interview, conducted during a site visit on 01/02/24, it was confirmed the facility failed to have a secured janitor closet for storing supplies and equipment; and have the capacity for locked storage of chemicals and equipment. Findings include, but are not limited to the following: In a walkthrough of Emerald house at 11:05 am on 01/02/24, the laundry room  'Out' door was observed to be partially ajar. Laundry detergent, laundry chemicals and cleaning chemicals were observed in the unlocked laundry room. In a walkthrough of Astor house at 1:39 pm on 01/02/24, the housekeeping closet was observed to be unlocked with a housekeeping cart and multiple chemicals present. At 1:41 pm, the laundry room was observed to be unlocked with laundry detergent and chemicals present. In an interview on 01/02/24, Staff 7 (med tech) stated the laundry room door lock in Emerald house is broken and maintenance is supposed to come fix it. S/he stated chemicals that staff use for cleaning get stored in the janitors closed which is locked. The facility failed to have a secured janitor closet for storing supplies and equipment; and have the capacity for locked storage of chemicals and equipment. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 2 (Life Enrichment Director). Facility Verbal Plan of Correction: The administrator will ensure maintenance fixes the broken lock on the laundry room door by the end of the day and they will have an in service to ensure staff know to keep chemical storage locked. Based on observation and interview, conducted during a site visit on 01/02/24, it was confirmed the facility failed to have a secured janitor closet for storing supplies and equipment; and have the capacity for locked storage of chemicals and equipment. Findings include, but are not limited to the following: In a walkthrough of Emerald house at 11:05 am on 01/02/24, the laundry room  'Out' door was observed to be partially ajar. Laundry detergent, laundry chemicals and cleaning chemicals were observed in the unlocked laundry room. In a walkthrough of Astor house at 1:39 pm on 01/02/24, the housekeeping closet was observed to be unlocked with a housekeeping cart and multiple chemicals present. At 1:41 pm, the laundry room was observed to be unlocked with laundry detergent and chemicals present. In an interview on 01/02/24, Staff 7 (med tech) stated the laundry room door lock in Emerald house is broken and maintenance is supposed to come fix it. S/he stated chemicals that staff use for cleaning get stored in the janitors closed which is locked. The facility failed to have a secured janitor closet for storing supplies and equipment; and have the capacity for locked storage of chemicals and equipment. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 2 (Life Enrichment Director). Facility Verbal Plan of Correction: The administrator will ensure maintenance fixes the broken lock on the laundry room door by the end of the day and they will have an in service to ensure staff know to keep chemical storage locked.”

“The findings of the kitchen inspection, conducted 10/02/23, 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 kitchen inspection, conducted 10/02/23, 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 survey of 10/02/23, conducted 12/06/23, 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 survey of 10/02/23, conducted 12/06/23, 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 second revisit to the kitchen inspection of 10/02/23, conducted 01/24/24, 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 second revisit to the kitchen inspection of 10/02/23, conducted 01/24/24, 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.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure proper food preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility kitchen was toured on 10/02/23, observations of the five facility kitchens, including food storage areas, food preparation, food service, and interviews with staff were conducted during the annual kitchen inspection. a. Emerald House, the main kitchen, was toured at 10:05 am and identified the following: * The exit door to the outside was fully opened, without a screen and allowed for the entry of pests; * Multiple trash cans lacked covers; * Air conditioning unit mounted above the ware washing area had brown splatters and debris buildup; * Ice machine interior lid and air vents had a buildup of debris; * The dry food storage area had less than a week supply of dry goods; * Interviews with multiple staff identified on multiple days throughout the week the kitchen doesn't have the ingredients to prepare and serve what was on the menu; * Interviews with staff also identified that there had been times that the kitchen didn't provide a written menu for residents; * Interior shelf walls of the steam table and prep table had a large area of brown matter; * Bottom shelf of the stainless-steel table to the right of the grill was covered in black matter and had a five gallon bucket of used food grease that had not been discarded; * Buildup of food debris and grease behind and underneath the stovetop, oven and grill; * Food splatter and debris buildup on the conveyor toaster and microwave; * Drawer underneath the toaster and drink counter had dirty serving utensils and debris that had fallen into the drawer; * Disposable food containers stored on the prep counter contained food splatter on them; * Drains beneath bakery table and underneath the sink next to bakery table had a buildup of food waste; * The walk-in freezer had food and debris on the floor; * The exhaust fan cage blowing into the walk-in refrigerator had dust and debris; * The walk-in refrigerator had multiple leftover food items that were beyond the discard date and continued to be stored on the refrigerator shelves; * Ready to eat meat products were improperly stored and shelved with produce and on the upper shelves; * Meat was wrapped in clear wrap or covered with parchment paper without a label or date; * Under counter reach-in Continental refrigerator had multiple food items that were uncovered, unlabeled and not dated; * Staff lacked knowledge of how to use sanitation test strips; * Staff lacked good infection control related to use of aprons, hair restraints and hand hygiene between dirty and clean tasks; * Multiple staff interviewed lacked knowledge of signs and symptoms of foodborne illness, transmission and prevention of foodborne illnesses including cross contamination and safe food handling processes; * Staff failed to take food temperatures for all food prior to transporting the food to the warmer for hot holding; and * Staff failed to ensure serving carts were clean and disinfected prior to placing plates and glasses for meal service to the dining room. b. Crown House kitchenette was toured at 12:05 pm and identified the following: * Splatters, spills, debris, drips were noted on the inside and outside of the microwave and toaster; * Staff were not using sanitation test strips for the stationary rack dishwasher; * The upright refrigerator was missing the temperature gauge; and * All staff failed to have verification of a valid Oregon Food Handler card. c. Barlow House kitchenette was toured at approximately 12:26 pm and identified the following: * Splatters, spills, debris, drips were noted on the inside and outside of the microwave and toaster; * The drain and surrounding floor under the single compartment sink had black/brown matter; * Drain underneath the two-compartment sink had a buildup of debris; * Floors throughout the kitchen was visibly soiled with dirt buildup, grass clippings, leaves and food debris; and * The backsplash by the two-compartment sink was pulling away from the wall. * Shelving used to store clean dishes had chipped laminate and was an unclean surface; and * Gouges on cupboard doors rendering the surface uncleanable. d. Diamond House kitchenette was toured at 12:37 pm and identified the following: * Splatters, spills, debris noted on the toaster, interior /exterior of the microwave and drain under the three compartment sink; * Multiple ceiling vents had buildup dust and debris; * Multiple leftover food items were not dated or labeled in the upright refrigerator; * Staff lacked knowledge and proper use of the three-compartment sink for sanitation of dishes; * There was inoperable stainless-steel reach in refrigerator left discarded in the back of the kitchen; and * All staff failed to have verification of a valid Oregon Food Handler card. e. Astor House kitchenette was toured at approximately 12:56 pm and the following was identified: * The upright refrigerator was missing the temperature gauge; * There was a two-inch hole in the floor near the center island prep table; * There was no soap dispenser for hand hygiene; * There were no sanitation test strips for the stationary rack dishwasher; and * There were splatters and food debris on the interior and exterior of the microwave and toaster. The above findings were discussed with Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 10/02/23 at 1:10 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure proper food preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility kitchen was toured on 10/02/23, observations of the five facility kitchens, including food storage areas, food preparation, food service, and interviews with staff were conducted during the annual kitchen inspection. a. Emerald House, the main kitchen, was toured at 10:05 am and identified the following: * The exit door to the outside was fully opened, without a screen and allowed for the entry of pests; * Multiple trash cans lacked covers; * Air conditioning unit mounted above the ware washing area had brown splatters and debris buildup; * Ice machine interior lid and air vents had a buildup of debris; * The dry food storage area had less than a week supply of dry goods; * Interviews with multiple staff identified on multiple days throughout the week the kitchen doesn't have the ingredients to prepare and serve what was on the menu; * Interviews with staff also identified that there had been times that the kitchen didn't provide a written menu for residents; * Interior shelf walls of the steam table and prep table had a large area of brown matter; * Bottom shelf of the stainless-steel table to the right of the grill was covered in black matter and had a five gallon bucket of used food grease that had not been discarded; * Buildup of food debris and grease behind and underneath the stovetop, oven and grill; * Food splatter and debris buildup on the conveyor toaster and microwave; * Drawer underneath the toaster and drink counter had dirty serving utensils and debris that had fallen into the drawer; * Disposable food containers stored on the prep counter contained food splatter on them; * Drains beneath bakery table and underneath the sink next to bakery table had a buildup of food waste; * The walk-in freezer had food and debris on the floor; * The exhaust fan cage blowing into the walk-in refrigerator had dust a”

“Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240. Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240. Refer to C240 Refer to C240 There are no detail notes for this visit.”

“Based on observation, 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 C 240. Based on observation, 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 C 240. Refer to C240 Refer to C240 Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. Refer to C240 Refer to C240 There are no detail notes for this visit.”

“Based on interview and record review, conducted during a site visit on 01/02/24, it was confirmed the facility failed to carry out medication orders as prescribed for 2 of 2 sampled residents (#'s 3 and 7). Findings include the following: a. A review of Resident 3's MAR from April 2022 and his/her physician orders dated 01/02/24 which indicated resident was not administered Metoprolol 25 mg from 04/15/22 - 04/20/22 due to the medication not being available. From 04/04/22 - 04/06/22 resident did not receive Tamsulosin 0.4 mg due to medication not being available. In an interview on 01/02/24, Staff 1 (Executive Director) there had been issues with getting Resident 3's medications ordered and delivered timely years ago, but it has since been resolved. b. A review of Resident 7's MAR from May 2022 and his/her physician orders dated 05/31/22 indicated multiple medications not documented on from 05/07/22 - 05/08/22 with no indication if medications were given or not. The facility failed to carry out medication orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 01/02/24. Facility Verbal Plan of Correction: The Executive Director had already taken steps to correct medication ordering issues with Resident 3, Resident 7 was no longer a resident. Based on interview and record review, conducted during a site visit on 01/02/24, it was confirmed the facility failed to carry out medication orders as prescribed for 2 of 2 sampled residents (#'s 3 and 7). Findings include the following: a. A review of Resident 3's MAR from April 2022 and his/her physician orders dated 01/02/24 which indicated resident was not administered Metoprolol 25 mg from 04/15/22 - 04/20/22 due to the medication not being available. From 04/04/22 - 04/06/22 resident did not receive Tamsulosin 0.4 mg due to medication not being available. In an interview on 01/02/24, Staff 1 (Executive Director) there had been issues with getting Resident 3's medications ordered and delivered timely years ago, but it has since been resolved. b. A review of Resident 7's MAR from May 2022 and his/her physician orders dated 05/31/22 indicated multiple medications not documented on from 05/07/22 - 05/08/22 with no indication if medications were given or not. The facility failed to carry out medication orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 01/02/24. Facility Verbal Plan of Correction: The Executive Director had already taken steps to correct medication ordering issues with Resident 3, Resident 7 was no longer a resident.”