The Arbor at Avamere Court.

“Based on observations, interviews, and record review, it was determined the facility failed to follow texture components of diet orders for 1 of 1 randomly selected resident (# 1) needing puree diet textures. The incorrect diet texture placed the resident at risk for aspiration and/or choking. Findings include, but are not limited to: Resident 1 had a current physician order dated 06/17/25 noting the following diet order: “Regular diet: Pureed Texture, IDDSI [International Dysphagia Diet Standardization Initiative] Moderately Thick consistency.” On 09/05/25 at approximately 11:30 am Resident 1 was observed to be given her meal. Shortly after taking the first bite resident was observed to start coughing. Care staff did respond and go to resident asking if they were ok. The resident did nod indicating they were “OK”. Resident took another bite and began coughing again. Staff intervened and offered the resident a drink of their thickened liquid which appeared to subside the cough. After a few minutes passed the resident took another bite and again began coughing. The surveyor went over to view the resident’s meal and the meal texture did not look smooth as was expected with appropriate texture. Surveyor went to the North Unit and observed a plated meal designated as puree that had yet to be given/served to a resident. Upon investigation of the food products revealed several big chunks of whole unprocessed pieces of vegetables (carrots and green beans) or meat and the overall texture was not smooth as needed/necessary for appropriately pureed textures. Surveyor instructed Staff 4 (Cook) the items as plated could not be served. Staff 4 acknowledged the whole chunks were not appropriate for puree textures and they would serve any remaining residents needing puree something else. Staff 4 acknowledged that all puree items were mechanicalized together in batches and then individual resident servings taken out of the batches confirming the observed texture of the meal for resident 1 was not appropriate. At approximately 12:20 pm, surveyor presented the incorrectly pureed food items to Staff 1 (Administrator) who acknowledged the unsmooth and larger pieces in the pureed items that would not be appropriate for a resident needing pureed textures. Staff 1 acknowledged the presented texture would be a potential safety issue for residents needing puree diet. Surveyor informed Staff 1 of the observation of Resident 1 difficulty with lunch meal and the multiple coughing episodes. Staff 1 verbalized understanding and acknowledged the lunch meal presented appeared to not be the correct and safe texture for residents needing puree. At approximately 1:00 pm, Surveyor interviewed both cooks on duty (Staff 4 and 5). Both cooks acknowledged the larger pieces observed in lunch for puree was not appropriate or safe for residents needing puree texture. Surveyor asked staff to demonstrate appropriate pureed food items and neither cook understood the appropriate level of smooth texture needed for puree textures. After demonstration by surveyor Staff 4 and 5 were then able to understand and demonstrate the correct level of mechanicalizing of food items to produce a smooth/appropriate puree textures. On 9/08/25 surveyor returned to facility for lunch meal preparation and service and validated puree textures were correct. Resident 1 was observed during lunch meal and was not observed to cough throughout the lunch observation. On 09/08/25 at 12:28 Staff 2 (Dining Services Director) was interviewed and acknowledged the facility had not been pureeing items correctly.”

“Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main facility kitchen and the North and South unit kitchenettes on 09/05/25 from 10:40 am through 2:00 pm and again on 09/08/25 from 10:00 am through 2:00 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Walls, and flooring behind/underneath of the dish machine; * Industrial mixer; * Industrial slicer; * Large can opener and housing; * Black tray holding clean dishes above service line; * Large can metal storage rack; * Speed rack in walk in cooler; * Metal rack in walk in freezer; * Interior of white bulk food storage container; * Top of dish machine; * Top of specialty coffee/cocoa machine; * Drain under dish machine; and * Juice machines in unit kitchenettes. b. The following areas needed repair: * Metal racks in walk in cooler had rust accumulation; c. Salad dressing containers in both units not dated with dates opened or use by dates. Salad dressing containers in deli cooler in main kitchen did not have open or use by dates. Multiple items noted in deli cooler without open dates. d. Multiple food items found past manufactures use by dates. Container of peperoni was observed well past use by date and visible signs of molding/spoilage were observed. e. Two large boxes of sprinkles found stored open to potential contamination. Ice cream bars in North unit freezer observed stored unwrapped/open to potential contamination. Containers of single use disposable utensils/service ware were stored open exposing items to potential contamination. f. Room trays for residents were observed on both units to be delivered/transported to the rooms without food or beverages covered/protected from potential contamination. g. A large soup kettle pot was observed stored in the walk-in cooler full of soup made the evening before. Staff were interviewed about proper cooling methods and time temperature guidelines to ensure safety. Staff were not able to discuss proper ways to cool items nor able to discuss temperature levels and time frames needed for safe storage. Staff verified the soup did not undergo any further steps to ensure safe storage. Staff 2 (Dietary Manager) was interviewed on 09/08/25 at 12:38 pm and acknowledged staff did not follow appropriate cooling steps and would discard the soup. h. The evening meal cook was not able to correctly state proper cook to temperatures for chicken/poultry. Menus were reviewed and multiple meals included chicken as a main entrée. i. Multiple bulk food items were found with scoops/utensils stored with hand contact areas touching food surfaces potentially contaminating the food product. j. White cutting boards were found heavily stained and scored and in need of replacement. Multiple fry pans observed with integrity issues. Multiple North unit resident reusable straws were found heavily stained and in need of replacement. k. Facility did not have the correct test strips to test/validate the surface sanitizer and three compartment sink sanitizer. Kitchen staff were not aware of the chemical used for sanitation and were not able to state the appropriate parts per million (PPM) needed for sanitation. Surveyor was able to validate sanitizer dispenser was dispensing correct concentration of sanitizer with surveyor provided strips. The incorrect chemical was posted on the dispenser. l. Kitchen staff did not have appropriate knowledge of puree diets to ensure diets were served as ordered. Puree food items for lunch on 09/05/25 were observed with visible chunks and/or large whole pieces of food mixed into the more mechanicalized pieces. There was no smooth blended texture observed to the food items. On 09/08/25 at 12:38 pm, Staff 2 was interviewed and acknowledged the facility was “doing puree wrong.” Staff 2 acknowledged they had not had any official training on puree textures. m. On both days of survey lunch meal was prepared and in ovens/warmers well before lunch service. On 09/05/25 lunch was in ovens/warmers at 10:40, at least one hour before service. On 09/08/25 lunch meal items were observed complete and in oven/warmers at 10:00am over 1 hr 30 minutes prior to meal service times. Staff 2 was interviewed regarding the possible reasons why meal items were cooked that far in advance of meal service times, and they indicated the staff have just done that since he started. Staff 2 was asked the barriers to preparing food closer to meal service times and he said there weren’t any. Staff 2 acknowledged cooking that far in advance with extended hot holding could continue to cook food and lead to potential food quality concerns/outcomes. On 09/08/25 at approximately 12:30 pm, Staff 2 was informed of above areas and acknowledged the needed correction. At 1:30 pm, the surveyor reviewed with Staff 1 (Administrator) the noted areas and they were acknowledged. 1-2a. Daily- clean speed rack, juice machines cleaned with each meal. Dry storage bins cleaned weekly 1-2b. Clean rust off metal racks in walk in and apply sealant 1-2c. Opened containers will have open dates 1-2d. Food deliveries will be checked for expiration dates and checked twice weekly 1-2e. Carton food items transferred to air tight containers. Freezers in units will be checked daily and opened food discarded. Utensils to be stored in airtight containers 1-2f. room trays will be covered with full tray covers that cover the entire tray during transport to rooms 1-2g.Soups stored in airtight containers, cooled with jamar cooling sticks in appropriate time frame 1-2h. education for cooks and temp charts posted for reference 1-2i.Using disposable scoops to throw away after each use to prevent contamination 1-2j. Replace cutting boards. Fry pans discarded. Using disposable straws for resident water bottles 1-2k. Correct test strips ordered and in community for use. Replace label for sanitizer. Inservice for PPM in sanitizer 1-2l.Puree textures will be checked for proper texture pror to service 1-2m. meals prepared and placed in holding no more than 30 minutes prior to meal service 3. All will be evaluated bi-weekly 4. Dining Services Manager/ED 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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main facility kitchen and the North and South unit kitchenettes on 12/04/25 from 9:40 am through 1:00 pm and revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Walls, ”

“Based on interview, observation and review of records, 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 C 240. See C240 OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:”

“Based on observations and interviews, 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 C160 and 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: Based on observations and interviews, 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, and C455. 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:”

“Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#4) who had documented medication refusals. Findings include, but are not limited to: Resident 1 was admitted to the facility in 12/2023 with diagnoses including dementia. A review of the resident's physician orders and 10/01/24 through 10/21/24 MAR identified the resident had refused multiple medication and treatments on 66 occasions. There was no documented evidence the physician had been notified of the refusals, or a signed order stating how often the physician would like to be notified of refusals. On 10/24/24, the need to ensure the facility notified physicians of medication refusals was discussed with Staff 1 (ED) and Staff 2 (Director of Health Services). They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 10/21/24. Exterior pathways in MCC courtyards contained multiple drop offs up to two inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents. On 10/22/24, the building's exterior was toured with Staff 1 (ED) and Staff 6 (Plant Operations Director). They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure the facility was clean, in good repair, and free of unpleasant odors. Findings include, but are not limited to: Observations of the Northside and Southside MCC units from 10/21/24 through 10/24/24 identified multiple walls, door frames, and window frames with chipped and missing paint in common areas. On 10/22/24, the areas in need of repair were toured with Staff 1 (ED) and Staff 6 (Plant Operations Director). They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure the facility was clean, in good repair, and free of unpleasant odors. Findings include, but are not limited to: Observations of the Northside and Southside MCC units from 10/21/24 through 10/24/24 identified multiple walls, door frames, and window frames with chipped and missing paint in common areas. On 10/22/24, the areas in need of repair were toured with Staff 1 (ED) and Staff 6 (Plant Operations Director). They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to information being accessible in common areas of the facility for 2 of 4 sampled residents (#s 2 and 3) and 2 unsampled residents. Findings include, but are not limited to: During the survey, 10/21/24 through 10/24/24, four resident room doors were observed to have notes attached which contained resident-specific information including their personal preferences and/or medical health information. The door notes were accessible for public viewing, which jeopardized the residents’ rights to privacy and dignity. The need to ensure resident privacy and dignity was reviewed with Staff 1 (ED) and Staff 2 (Director of Health Services) on 10/24/24. They acknowledged the findings.”

“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 C510 and C513. Refer to C510 and 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 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 C305. Refer to C305 OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:”

“based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individualized activity plan based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3 and 4 resided in the Memory Care Community and were diagnosed with dementia. Each resident was observed needing various degrees of assistance to initiate and participate in activities. Resident 1 was observed self-propelling around the unit in a wheelchair. The resident observed several activities but did not actively participate. Resident 2 was recently admitted to the facility. Resident 2 was able to ambulate independently and spent most of the day in his/her room watching TV. Resident 3’s condition had recently declined leaving him/her bedbound, needing increased assistance with many ADLs and sleeping a lot during the day. No activities were observed to be offered to the resident during the survey. Resident 4 was recovering from a recently diagnosed urinary tract infection which contributed to increased confusion and aggressive behaviors toward staff. During the survey, the resident was observed sleeping on couches or in other common areas and did not participate in activities. Resident 1, 2, 3 and 4's service plans were reviewed. Though the activity section of the service plan offered some information about the residents’ past and current interests, information about one or more of the following areas was lacking: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. The need to develop individualized activity plans which were based on a thorough assessment of the residents’ interests, abilities and needs was discussed with Staff 1 (ED) and Staff 2 (Director of Health Services) on 10/24/24. They acknowledged the findings and reported they were already implementing new processes to improve all residents’ activity plans.”

“Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main facility kitchen and the North and South unit kitchenettes on 10/15/24 from 11:00 am thru 1:15 pm and revealed the following deficient practices. 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: * Pipes, walls, and flooring behind/underneath of the dish machine; * Ceiling vents; * Industrial mixer; * Industrial slicer; * Large can opener and housing; * Reach in deli cooler; * Tray holding clean dishes; * Interior of ice scoop holder; * Interior of ice machine * Interior of both unit kitchen ovens; b. The following areas needed repair: * Caulking in ware washing area with black matter debris buildup; * Large accumulation of water under dishwasher and in dishwashing area. * Large scale build up in dishwasher. * Industrial dishwasher was not washing at 150 degrees Fahrenheit as required. * Steamer out of service due to scale build up. * Water damage to areas behind sinks in both North and South units. * Plug in to hot cart in North unit not working and unable to plug in to keep items warm when delivered to units. c. Multiple food items/packages/containers found in reach in deli cooler that were not dated when opened/prepared. Salad dressing containers in both units not dated with dates opened or use by dates. d. Multiple cooking pans and were found in poor repair (heavy carbon/grease build up and/or non stick coating with scratches) and were in need of replacement. e. Large bag of oats found in dry storage open and exposed to potential contamination. Large boxes of single use disposable utensils were stored open exposing utensils to potential contamination. f. Multiple open fly/insect trap paper strips were located throughout the kitchen area with multiple visible dead insect carcasses attached hanging above areas with clean dishes and food transport areas. g. Multiple care staff assisting residents to eat did not have a protective barrier/aprons on to help prevent potential contamination from care tasks to meal/dining tasks. 2 care staff in South unit observed handling either an iPad or pager then proceed to assist residents with meals and/or getting drinks including handling straws without a hand hygiene step. h. Care staff was observed in both units to transport resident meals/desserts or beverages without being covered/protected from potential contamination. i. Per interview with staff 2 (Director of Food Service) at approximately 12:30 pm, residents receiving pureed textures where not served the current days menu items. All purred meals were from previous days menu items. Staff 2 acknowledged this practice was not due to resident choices or wishes to have the previous days menu items and was for facility convenience. Staff 2 stated they were unaware that was not an acceptable practice. Staff 2 stated they would begin pureeing foods for residents with that texture according to what was on the posted menu for all residents, unless it was at the specific request of the resident as per their right. At this time, surveyor reviewed the above identified areas in need of correction with staff 2. Staff 2 acknowledged the areas. At 1:00 pm, Staff 1 (Business Office manager) was informed of the concerns found and they acknowledged the need for correction. DSM is monitoring cleaning schedules and ensuring they are followed and adhered to at all times, descaling is being done to equipment on a regular basis. Steamer will be replaced. Plant ops will repair any areas noted in SOD, up to and including any leaks, water damaged areas, caulking and any equpiment that is not working properly. DSM ensuring proper dating of and storage of food items at all times. Cookware has been replaced.Insect paper has been removed. Staff are wearing aprons during all meal service times and all food being transported is covered to prevent contamination. ED, DSM and Plant Ops will be responsible to see that these corrections are made and ED will be checking weekly to ensure these protocols are being followed 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 observations and interviews, 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. Please refer to tag C0240 and its plan of correction 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:”

“The findings of the kitchen inspection, conducted 12/20/23, are documented in this report. It was determined the facility was in 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 12/20/23, are documented in this report. It was determined the facility was in 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.”