Courtyard at Mt Tabor Garden House.

“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 12/11/25 at 10:40 am, the facility kitchen was observed to need cleaning in the following areas: * Ice maker interior – significant pink matter build up; * Hood vents – greasy/dusty; * Door handles on oven doors – sticky/tacky; * Shelf above grill/stove – greasy; * Commercial can opener – food debris/black matter/blade finish worn; * Lids of food bins – food debris build up; * Floor drain – heavily stained; * Caulking above splash guard behind spray hose in dishwashing area – black matter build up; and * Wall beneath spray hose sink in dishwashing area – heavy build up of brown drips/splatter. Other concerns included: * Multiple garbage cans uncovered when not in use; and * Colored cutting board – heavily scored and worn. The areas of concern were observed and discussed with Staff 1 (Food & Beverage Director) and discussed with Staff 2 (Assistant Executive Director) on 12/11/25. The findings were acknowledged. What actions will be taken to correct the violation for each example/resident:”

“Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Refer to C240 above What actions will be taken to correct the violation for each example/resident:”

“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 02/27/25.  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 02/27/25.  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 02/27/25, the facility's failure to carry out medication orders for 1 of 1 sampled Resident (# 1) was substantiated. Findings include, but are not limited to: Resident 1's service plan, dated 01/22/24, indicated Resident 1 was a total assist with medication, Med Tech to administer Resident 1's medications per physician's orders as noted on the MAR, and Staff to follow orders and administer all medications as directed. Resident 1's MAR, dated 06/01/23 through 06/30/23, indicated Resident 1 had scheduled Olanzapine 2.5 mg tab (dementia related anxiety) with the instructions: "[one] tablet by mouth every evening after dinner," and Olanzapine 2.5 mg tab (agitation) with the instructions "[one] tablet by mouth every day as needed for severe agitation/distress/anxiety." Resident 1's MARs, dated 07/01/23 through 11/30/23, indicated Olanzapine 2.5 mg tab was listed twice on the MAR under "as needed" medications. Resident 1's MARs, dated 12/01/23 through 12/31/23, indicated Olanzapine 2.5 mg tab was listed three times on the MAR under "as needed" medications. The MAR indicated Olanzapine 2.5 mg tab was discontinued on 12/07/23. Resident 1's narrative charting, dated 06/01/23 through 12/31/23, indicated on 06/29/23, Resident 1 received new orders for Olanzapine 2.5 mg. Resident 1's physician orders, dated 05/19/23, indicated on 05/19/23, Resident 1 was prescribed Olanzapine 2.5 mg tablet with the instructions "Take [one] tablet by mouth daily as needed in addition to schedule dose for severe agitation/distress/anxiety that is not alleviated with nonpharmacologic strategies first," and Olanzapine 2.5 mg tablet with the instructions "Take [one] tablet by mouth every evening: give after dinner for dementia related anxiety/distress." The facility self-report, dated 12/07/23, indicated Resident 1's scheduled Olanzapine order was entered incorrectly by the pharmacy and Resident 1 had not been administered his/her scheduled Olanzapine since 06/27/23. Staff 1 (Director of Resident Services) stated Resident 1 did not receive the scheduled medication for some time. The pharmacy had incorrectly transcribed the medication on the MAR and entered it "as needed" and not scheduled. It was determined the facility's failure to carry out medication orders for Resident 1 was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Residential Care Facility Administrator), and Staff 3 (Assistant Administrator). Based on interview and record review, conducted during a site visit on 02/27/25, the facility's failure to carry out medication orders for 1 of 1 sampled Resident (# 1) was substantiated. Findings include, but are not limited to: Resident 1's service plan, dated 01/22/24, indicated Resident 1 was a total assist with medication, Med Tech to administer Resident 1's medications per physician's orders as noted on the MAR, and Staff to follow orders and administer all medications as directed. Resident 1's MAR, dated 06/01/23 through 06/30/23, indicated Resident 1 had scheduled Olanzapine 2.5 mg tab (dementia related anxiety) with the instructions: "[one] tablet by mouth every evening after dinner," and Olanzapine 2.5 mg tab (agitation) with the instructions "[one] tablet by mouth every day as needed for severe agitation/distress/anxiety." Resident 1's MARs, dated 07/01/23 through 11/30/23, indicated Olanzapine 2.5 mg tab was listed twice on the MAR under "as needed" medications. Resident 1's MARs, dated 12/01/23 through 12/31/23, indicated Olanzapine 2.5 mg tab was listed three times on the MAR under "as needed" medications. The MAR indicated Olanzapine 2.5 mg tab was discontinued on 12/07/23. Resident 1's narrative charting, dated 06/01/23 through 12/31/23, indicated on 06/29/23, Resident 1 received new orders for Olanzapine 2.5 mg. Resident 1's physician orders, dated 05/19/23, indicated on 05/19/23, Resident 1 was prescribed Olanzapine 2.5 mg tablet with the instructions "Take [one] tablet by mouth daily as needed in addition to schedule dose for severe agitation/distress/anxiety that is not alleviated with nonpharmacologic strategies first," and Olanzapine 2.5 mg tablet with the instructions "Take [one] tablet by mouth every evening: give after dinner for dementia related anxiety/distress." The facility self-report, dated 12/07/23, indicated Resident 1's scheduled Olanzapine order was entered incorrectly by the pharmacy and Resident 1 had not been administered his/her scheduled Olanzapine since 06/27/23. Staff 1 (Director of Resident Services) stated Resident 1 did not receive the scheduled medication for some time. The pharmacy had incorrectly transcribed the medication on the MAR and entered it "as needed" and not scheduled. It was determined the facility's failure to carry out medication orders for Resident 1 was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Residential Care Facility Administrator), and Staff 3 (Assistant Administrator).”

“Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, kitchen staff did not follow hygienic practices, and proper food handling procedures were not followed in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 12/26/24 at 10:02 am the main kitchen, walk-in refrigerator and freezer were observed to need cleaning in the following areas: a. Kitchen area: * Pooling of a large amount of charred oil was observed on the floor on either side of the stove; * Pipes behind multiple appliances had grease, dirt, and debris on them; * Cooktop knobs and handles had sticky matter, built-up grease and dried food debris on them; * Interior walls of the ice-maker machine had unidentified yellow residue; * Cooktop and burners were covered with burnt-on grease and other residue; * Range hood filters were covered with grease; * Air return duct cover above the tray line was covered with dust; * Cooling racks had rust on them; * Waffle iron was covered with dirt and grease; and * Knobs, doors, and handles of various kitchen appliances were missing or covered with grease. b. Walk-in refrigerator and freezer: * Refrigerator and freezer cooling unit fans had a layer of dust and dirt. Ready-to-serve items stored under the cooling unit in the refrigerator were uncovered and open to direct dust and debris contamination from blowing fan; * Liquid discharge from box of defrosted meat products had leaked onto the refrigerator floor; and * Exterior surfaces and handles were covered with sticky residue. On 12/26/24 at 10:02 am, the main kitchen was observed to need the following repairs: * The molding around the door frame connecting the sous chef office and the main kitchen was missing and/or damaged, exposing underlying drywall and holes in the wall; * Holes in the ceiling up to approximately 6 inches surrounded the copper pipes from various appliances; * Displaced ceiling tile in dishwashing room in the far left corner exposing ventilation duct; * Drop ceiling tiles were cracked, missing, or out-of-place; and * Cabinets under serving station were missing doors. On 12/26/24 at 11:00 am, the following improper food handling practices were observed: * Multiple kitchen staff was observed using single-use gloves for multiple tasks, including food handling, cooking and operating appliances; * Industrial mixer was not covered when not in use as required; * Individual portions of food were plated on trays in the walk-in refrigerator and left uncovered; and * Multiple food items in the walk-in refrigerator and walk-in freezer were found not dated and only partially wrapped. Bulk food items were found not dated after opening. Kitchen staff was observed not following proper hygienic practices: * Kitchen staff were not wearing aprons when cooking and serving food; and * Three garbage cans in the kitchen were not covered with lids when not in use. Staff 5 (Cook), Staff 6 (Cook), and Staff 7 (Cook) did not have current food handler's permits. The findings were discussed with Staff 1 (Associate ED) and Staff 2 (Sous Chef) on 12/26/24. Both staff acknowledged the findings. c. On12/26/24 from 10:00 am to 10:10 am, an inspection of the kitchenette area in the memory care was conducted. The following observations were made: * A brown substance was present underneath the sink; * Five beverage jars in the refrigerator were uncovered and undated; * Premade thickened liquid beverages were open, but lacked labeling or dates; * The interior of the microwave in the second dining room was stained with a brown residue and the exterior surface was sticky to the touch; and * Cabinets and drawer surfaces were sticky to the touch and contained open salt and sugar containers in the drawers. In an interview on 12/26/24 at 11:24 am, Staff 4 (MT) stated “never made it clear” who was responsible for cleaning the refrigerator. The areas that required cleaning were observed and discussed with Staff 3 (Connections for Living Director) on 12/26/24 at 12:18 pm. The staff acknowledged the area needed cleaning. d. The MCC had 15 residents at the time of survey. There were 11 residents in the dining room for lunch on 12/26/24 and lunch service was observed from 11:47 am through 12:07 pm. During the observation, a caregiving staff provided 1-on-1 meal assistance to a resident. The caregiving staff was not wearing an apron or other type of barrier to prevent the potential cross contamination when providing meal assistance. Staff were observed setting tables with napkins and silverware, serving meals and beverages, and then clearing dirty dishes. During the process, staff touched residents, handled sandwiches on plates, and moved in and out of the dining room to retrieve juice and milk. Meals were served to residents without the staff changing their gloves or performing proper hand hygiene. The above observation was discussed with Staff 3 on 12/26/24 at12:23 pm. The staff acknowledged the findings. Section a: Kitchen Area Q1. What Actions will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean of the kitchen and appliances is scheduled for January 18th to ensure kitchen is in compliance. A Back of House All Staff meeting is scheduled for January 20th re-educate staff on compliance policies and procedures. Q2. How will the system be corrected so the violation will not happen again. The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. As such, we have had turnover in the position and the new Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not be in compliance. a. All cleaning, temperature, and other relevant logs are confirmed to be in their accurate locations, accessible, and clear. b. Cleaning schedules and assignments have been posted for the kitchen and dining room areas. Each item needing to be cleaned and the frequency of cleaning are included on the cleaning schedule. c. Monthly In-service for Dining staff has been scheduled and attendance is mandatory. Q3. How often will the area needing correction will be evaluated? Daily through substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Section b. Walk-in refrigerator and freezer: Q1. What Actions will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean of the kitchen and appliances is scheduled for January 18th to ensure kitchen is in compliance. A Back of House All Staff meeting is scheduled for January 20th re-educate staff on compliance policies and procedures. Q2. How the system will be corrected so this violation will not happen again? A cleaning schedule has been placed for the kitchen. Each item needing to be cleaned and the frequency of cleaning has been included on the cleaning schedule. A training for all Back of the house kitchen team has been sc”

“Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240. Q1. What actions will be taken to correct the rule violation? The team will utilize MBK senior living procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Re-education, Training and corrective actions, according to policy have been implemented. A Back of House All Staff meeting is scheduled for March 23rd re-educate staff on compliance policies and procedures. Q2. How will the system be corrected so this violation will not happen again? The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. The Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not comply. Q3. How often will the area needing correction will be evaluated? A. Daily, weekly and Quarterly inspections to ensure thorough and substantial compliance. Ongoing per policy. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025 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 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. Z 142 corresponds with the above C240. The Plan of Correction above for C240 will be implemented for the purposes of bringing Z142 into complaince. 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, 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 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: 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 01/31/24, 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 01/31/24, 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.”