Footsteps at Carman Oaks.

“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. Please 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 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 06/26/25 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: Main kitchen located in the independent living portion of the campus: * Interior of ice maker – pink/black matter; * Wall behind ice maker – build up of dust; * Wall under counter with toaster – brown matter drips/spills; * Vents above service line – build up of dust; * Hood vents in prep area – build up of dust/grease; *Lower shelves in prep area – drips/spills/splatters; * Bread storage rack in dry food storage – significant build up of food debris; * Walls and caulking in dishwashing areas behind spray hose sink and above three compartment sinks – significant build up of black matter; * Bottom shelf in freezer in prep area – significant food debris; * Hood above dishwashing machine – significant build up of black matter/dust; and * Top of dishwashing machine - significant build up of dried debris. Improper food storage: * Dry food storage – multiple bags of food opened without being dated. Service kitchen for Springs/Footsteps: * Commercial can opener – finish worn off blade and significant black matter on housing. The areas of concern were observed and discussed with Staff 1 (Food & Beverage Director) and discussed with Staff 2 (Health Services Administrator) and Staff 3 (Executive Director) on 06/26/25. The findings were acknowledged.”

“Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#6). Findings include, but are not limited to: A review of Resident 6's Medication Administrator Record (MAR), dated 06/01/24 to 06/30/24, indicated Amlodipine (a blood pressure medication) 2.5 MG tab, one tablet by mouth every evening, for essential hypertension. A review of a facility incident report, dated 07/02/24, indicated that on 06/30/24, Resident 6 "received in error Amlodipine 5 mg tab instead of 2.5 MG tab." In an interview on 02/06/25, Staff 1 (Administrator) agreed with the documentation and stated the error did occur. The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25. Verbal Plan of correction: The facility has completed training with all MTs, including the specific MT related to the event on 6 rights of medication. They have monthly MT meetings, if things come up in between they provide additional re-training. Facility RN completes one on one and additional training when necessary. -------------------------------------------------------------------------------------------------------------------- Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#4). Findings include, but are not limited to: A review of Resident 4's signed physician orders dated 12/24/23 revealed: *Sennosides 8.6 mg tablet take 2 tablets by mouth (17.2 mg total at bed time). Hold for diarrhea; and *Stopped medication: cephalexin 250 mg tablet. A review of Resident 4's 12/01/23 through 12/31/23 MAR revealed: *On 12/25/23 Resident 4 received two doses of sennosides, instead of one. *On 12/25/23 and 12/26/23 Resident 4 received discontinued cephalexin. During an interview on 02/05/25, Staff 1 (Administrator) stated the medication errors did occur and was reported to Adult Protective Services. The facility's failure to carry out medication orders as prescribed was substantiated. The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25. ------------------------------------------------------------------------------------------------------------------------- Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#5). Findings include, but are not limited to: A review of an incident report dated 04/09/23 revealed Resident 5 was given metoprolol (a blood pressure medication) by accident. Resident 5's MAR dated 04/01/23 through 04/30/23 did not contain any evidence of an order for metoprolol. Resident 5's progress notes for 04/05/23 through 04/24/23 revealed Resident 4 received metoprolol on 04/09/23 with no negative effects. During an interview on 02/05/25, Staff 1 agreed with the reviewed documentation. The facility's failure to carry out medication orders as prescribed was substantiated. The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25. Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#6). Findings include, but are not limited to: A review of Resident 6's Medication Administrator Record (MAR), dated 06/01/24 to 06/30/24, indicated Amlodipine (a blood pressure medication) 2.5 MG tab, one tablet by mouth every evening, for essential hypertension. A review of a facility incident report, dated 07/02/24, indicated that on 06/30/24, Resident 6 "received in error Amlodipine 5 mg tab instead of 2.5 MG tab." In an interview on 02/06/25, Staff 1 (Administrator) agreed with the documentation and stated the error did occur. The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25. Verbal Plan of correction: The facility has completed training with all MTs, including the specific MT related to the event on 6 rights of medication. They have monthly MT meetings, if things come up in between they provide additional re-training. Facility RN completes one on one and additional training when necessary. -------------------------------------------------------------------------------------------------------------------- Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#4). Findings include, but are not limited to: A review of Resident 4's signed physician orders dated 12/24/23 revealed: *Sennosides 8.6 mg tablet take 2 tablets by mouth (17.2 mg total at bed time). Hold for diarrhea; and *Stopped medication: cephalexin 250 mg tablet. A review of Resident 4's 12/01/23 through 12/31/23 MAR revealed: *On 12/25/23 Resident 4 received two doses of sennosides, instead of one. *On 12/25/23 and 12/26/23 Resident 4 received discontinued cephalexin. During an interview on 02/05/25, Staff 1 (Administrator) stated the medication errors did occur and was reported to Adult Protective Services. The facility's failure to carry out medication orders as prescribed was substantiated. The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25. ------------------------------------------------------------------------------------------------------------------------- Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#5). Findings include, but are not limited to: A review of an incident report dated 04/09/23 revealed Resident 5 was given metoprolol (a blood pressure medication) by accident. Resident 5's MAR dated 04/01/23 through 04/30/23 did not contain any evidence of an order for metoprolol. Resident 5's progress notes for 04/05/23 through 04/24/23 revealed Resident 4 received metoprolol on 04/09/23 with no negative effects. During an interview on 02/05/25, Staff 1 agreed with the reviewed documentation. The facility's failure to carry out medication orders as prescribed was substantiated. The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25.”

“Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to keep all medications administered by the facility stored in locked containers in a secured environment such as a medication room or medication cart was substantiated for 1 of 1 sampled resident (#3). Findings include, but are not limited to: A review of resident 3's progress note dated 07/16/24 revealed Resident 3's eye drops were misplaced by staff and the facility paid for a replacement bottle of the eye drops. During an interview on 02/05/25, Staff 1 (Administrator) confirmed a facility MT had misplaced Resident 3's eye drop bottle and it was found by another resident's family member. The facility's failure to keep all medications administered by the facility stored in locked containers in a secured environment such as a medication room or medication cart was substantiated. The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25. Verbal Plan of correction: The facility has completed training with all MTs, including the specific MT related to the event on 6 rights of medication. They have monthly MT meetings, if things come up in between they provide additional re-training. Facility RN completes one on one and additional training when necessary. Based on interview and record review, conducted during a site visit on 02/05/25 and 02/06/25, the facility's failure to keep all medications administered by the facility stored in locked containers in a secured environment such as a medication room or medication cart was substantiated for 1 of 1 sampled resident (#3). Findings include, but are not limited to: A review of resident 3's progress note dated 07/16/24 revealed Resident 3's eye drops were misplaced by staff and the facility paid for a replacement bottle of the eye drops. During an interview on 02/05/25, Staff 1 (Administrator) confirmed a facility MT had misplaced Resident 3's eye drop bottle and it was found by another resident's family member. The facility's failure to keep all medications administered by the facility stored in locked containers in a secured environment such as a medication room or medication cart was substantiated. The findings were reviewed with and acknowledged by Staff 1, Staff 2 (RSC) and Staff 5 (Executive Director) on 02/06/25. Verbal Plan of correction: The facility has completed training with all MTs, including the specific MT related to the event on 6 rights of medication. They have monthly MT meetings, if things come up in between they provide additional re-training. Facility RN completes one on one and additional training when necessary.”

“The findings of the kitchen inspection, conducted 05/30/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 05/30/24, 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 the kitchen inspection, conducted 08/09/23, are documented in this report. It was determined that 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 the kitchen inspection, conducted 08/09/23, are documented in this report. It was determined that 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.”