Emerson House Portland.
Emerson House Portland is Ranked in the bottom 22% on repeat-citation rate among Oregon peers with 24 OR DHS citations on record; last inspected Jul 2025.
A large home, reviewed on public record.
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Compared to 56 Oregon facilities with a similar number of beds.
ALF memory care · 36-month window. Higher percentile = better performance on inspection record. Source: Oregon Dept. of Human Services · Long-Term Care Licensing.
Rankings based on 36-month OR-DHS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · FREE
Emerson House Portland has 24 citations on record. Know the moment anything changes.
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Citation history, plotted month by month.
24 deficiencies on record. Each bar is a month with a citation.
Finding distribution
24 total · 36 monthsScope × Severity (CMS A–L)
Every inspection visit, verbatim.
5 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-07-31Annual Compliance VisitOR-cited · 6 findings
Plain-language summary
During this re-licensure inspection in July 2025, the facility was found to have failed to immediately investigate multiple skin injuries of unknown cause on one resident to rule out abuse or neglect, including a skin tear and several abrasions documented between April and July 2025. The facility also violated infection prevention protocols during meal service, with staff observed handling food and serving residents without changing gloves, washing hands, or using protective coverings, and food was delivered uncovered from the kitchen. Additionally, the facility failed to ensure newly hired staff completed required first aid, abdominal thrust, LGBTQIA2S+ training, and orientation training within required timeframes.
“Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause to rule out abuse or neglect for 1 of 1 resident (#4) who had injuries of unknown cause. Findings include, but are not limited to: Resident 4 moved into the MCC in 07/2023 with diagnoses including Alzheimer’s disease and macular degeneration with blindness. The resident was identified in the acuity interview as dependent on staff for all ADL care, including two-person assist with Hoyer lift for transfers and incontinence care. S/he used a tilt-in-space wheelchair with one-person staff assistance for mobility. The resident’s 04/01/25 to 07/28/25 progress notes, outside provider notes, RN skin care progress notes, and investigations were reviewed. The following was identified: HH RN notes indicated the resident experienced the following skin injuries: * 04/03/25 – left lateral forearm skin tear; * 04/10/25 – right calf abrasion, right knee abrasion, and left calf abrasion; * 04/21/25 – posterior thigh [location and type of skin injury not documented]; and * 04/28/25 – left shin abrasion. There was no documented evidence immediate investigations to rule out abuse or neglect were conducted for the above injuries of unknown cause. In an interview at 9:08 am on 07/30/25, Staff 1 (ED) stated the resident’s wheelchair at the time may have been the cause of the injuries. She confirmed the lack of investigations to rule out abuse or neglect.”
“Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to: Lunch service was observed on 07/28/25 through 07/30/25. The following was identified: * Staff were observed setting tables with napkins and silverware, serving meals and beverages, touching residents, entering and exiting resident rooms, and removing dirty dishes without changing their gloves or performing hand washing. * Caregiving staff on the first floor were observed serving food without wearing a protective covering over potentially contaminated clothing. * Food delivered from the kitchen was observed uncovered. The need to maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) on 07/31/25. She acknowledged the findings.”
“Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 13) completed first aid and abdominal thrust training within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 2 (Assistant ED) on 07/30/25 and showed the following: * Training records for Staff 8 (CG), hired 06/01/25, and Staff 13 (MT), hired 06/12/25, lacked documented evidence either first aid or abdominal thrust training was completed within 30 days of hire. The need to ensure staff completed first aid and abdominal thrust training within 30 days of hire was reviewed with Staff 1 (ED) and Staff 2 on 07/30/25. They acknowledged the findings.”
“based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 sampled newly hired staff (#s 8, 13, and 15) completed the department-approved LGBTQIA2S+ training prior to beginning their job responsibilities and 2 of 3 sampled long term staff (#s 4 and 7) completed the department approved LGBTQIA2S+ training prior to 12/31/24. Findings include, but are not limited to: Refer to Z155.”
“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: C231, C295, and C372.”
“Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 8, 13, and 15) completed all orientation and pre-service and dementia training topics prior to performing any job duties; 2 of 3 newly hired staff (#s 8 and 13) demonstrated competency in all required areas within 30 days of hire; 2 of 3 long term staff (#s 7 and 12) completed the required number of annual in-service training hours; and 2 of 3 long term staff (#s 4 and 7) completed the required LGBTQIA2S+ training. Findings include, but are not limited to: A review of staff training records with Staff 2 (Assistant ED) on 07/30/25 at 10:19 am identified the following: a. There was no documented evidence Staff 8 (CG), Staff 13 (MT), and Staff 15 (Cook), hired 06/01/25, 06/12/25, and 06/19/25, respectively, had completed all orientation, pre-service training topics, and dementia training prior to performing any job duties, including one or more of the following: * Abuse reporting requirements; * Fire safety and emergency procedures; and * Approved LGBTQIA2S+ course. b. There was no documented evidence Staff 8 and Staff 13 had completed all dementia training prior to performing any job duties, including all of the following: * Environmental factors that are important to a resident’s well-being; * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 8 and Staff 13 had demonstrated competency in all required areas within 30 days of hire, including the following: * Changes associated with normal aging. d. There was no documented evidence Staff 7 (CG) and Staff 12 (CG), hired 03/19/20 and 05/18/21, respectively, had completed at least 10 hours of annual in-service training related to the provision of care in CBC within their anniversary date of hire. e. There was no documented evidence Staff 4 (CG), hired 06/08/20, and Staff 7 had completed the required LGBTQIA2S+ training. The need to ensure staff training requirements were completed in the specified time frames was discussed with Staff 1 (ED) and Staff 2 on 07/30/25. They acknowledged the findings.”
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Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause to rule out abuse or neglect for 1 of 1 resident (#4) who had injuries of unknown cause. Findings include, but are not limited to: Resident 4 moved into the MCC in 07/2023 with diagnoses including Alzheimer’s disease and macular degeneration with blindness. The resident was identified in the acuity interview as dependent on staff for all ADL care, including two-person assist with Hoyer lift for transfers and incontinence care. S/he used a tilt-in-space wheelchair with one-person staff assistance for mobility. The resident’s 04/01/25 to 07/28/25 progress notes, outside provider notes, RN skin care progress notes, and investigations were reviewed. The following was identified: HH RN notes indicated the resident experienced the following skin injuries: * 04/03/25 – left lateral forearm skin tear; * 04/10/25 – right calf abrasion, right knee abrasion, and left calf abrasion; * 04/21/25 – posterior thigh [location and type of skin injury not documented]; and * 04/28/25 – left shin abrasion. There was no documented evidence immediate investigations to rule out abuse or neglect were conducted for the above injuries of unknown cause. In an interview at 9:08 am on 07/30/25, Staff 1 (ED) stated the resident’s wheelchair at the time may have been the cause of the injuries. She confirmed the lack of investigations to rule out abuse or neglect. Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to: Lunch service was observed on 07/28/25 through 07/30/25. The following was identified: * Staff were observed setting tables with napkins and silverware, serving meals and beverages, touching residents, entering and exiting resident rooms, and removing dirty dishes without changing their gloves or performing hand washing. * Caregiving staff on the first floor were observed serving food without wearing a protective covering over potentially contaminated clothing. * Food delivered from the kitchen was observed uncovered. The need to maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) on 07/31/25. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 13) completed first aid and abdominal thrust training within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 2 (Assistant ED) on 07/30/25 and showed the following: * Training records for Staff 8 (CG), hired 06/01/25, and Staff 13 (MT), hired 06/12/25, lacked documented evidence either first aid or abdominal thrust training was completed within 30 days of hire. The need to ensure staff completed first aid and abdominal thrust training within 30 days of hire was reviewed with Staff 1 (ED) and Staff 2 on 07/30/25. They acknowledged the findings. based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 sampled newly hired staff (#s 8, 13, and 15) completed the department-approved LGBTQIA2S+ training prior to beginning their job responsibilities and 2 of 3 sampled long term staff (#s 4 and 7) completed the department approved LGBTQIA2S+ training prior to 12/31/24. Findings include, but are not limited to: Refer to Z155. 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: C231, C295, and C372. Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 8, 13, and 15) completed all orientation and pre-service and dementia training topics prior to performing any job duties; 2 of 3 newly hired staff (#s 8 and 13) demonstrated competency in all required areas within 30 days of hire; 2 of 3 long term staff (#s 7 and 12) completed the required number of annual in-service training hours; and 2 of 3 long term staff (#s 4 and 7) completed the required LGBTQIA2S+ training. Findings include, but are not limited to: A review of staff training records with Staff 2 (Assistant ED) on 07/30/25 at 10:19 am identified the following: a. There was no documented evidence Staff 8 (CG), Staff 13 (MT), and Staff 15 (Cook), hired 06/01/25, 06/12/25, and 06/19/25, respectively, had completed all orientation, pre-service training topics, and dementia training prior to performing any job duties, including one or more of the following: * Abuse reporting requirements; * Fire safety and emergency procedures; and * Approved LGBTQIA2S+ course. b. There was no documented evidence Staff 8 and Staff 13 had completed all dementia training prior to performing any job duties, including all of the following: * Environmental factors that are important to a resident’s well-being; * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 8 and Staff 13 had demonstrated competency in all required areas within 30 days of hire, including the following: * Changes associated with normal aging. d. There was no documented evidence Staff 7 (CG) and Staff 12 (CG), hired 03/19/20 and 05/18/21, respectively, had completed at least 10 hours of annual in-service training related to the provision of care in CBC within their anniversary date of hire. e. There was no documented evidence Staff 4 (CG), hired 06/08/20, and Staff 7 had completed the required LGBTQIA2S+ training. The need to ensure staff training requirements were completed in the specified time frames was discussed with Staff 1 (ED) and Staff 2 on 07/30/25. They acknowledged the findings.
2025-02-11Annual Compliance VisitOR-cited · 4 findings
Plain-language summary
A kitchen inspection on February 11, 2025, followed by a revisit on April 30, 2025, found that the facility failed to maintain adequate administrative oversight of food services, with deficiencies including food debris and black matter on floors, equipment, and walls; dust buildup on ceiling vents and refrigeration units; grease behind the stove; wear on cutting boards and a can opener; and uncovered garbage. The facility's initial plan of correction was not implemented, and the revisit confirmed these issues remained unresolved. The facility has since submitted a new corrective plan that includes daily floor cleaning, monthly deep cleaning of ceiling vents and equipment, and scheduled maintenance tasks to address the sanitation violations.
“Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations for food services. Findings include, but are not limited to: During the first revisit of the kitchen inspection of 02/11/25, conducted 04/30/25, administrative oversight to ensure adequate food services rendered in the facility was found to be ineffective based on failure to implement plan of correction and ensure adequate oversight to correct deficiencies. Refer to deficiencies in the report. Co240: A) what will be fixed about this problem is a new cleaning chart. A new updated cleaning chart will be placed starting today, May 23rd 2025. This will indicate scrubbing the floor with a scrubby broom instead of a mop head every night, every day. Walls above the fridges and freezer including the vents will be a monthly cleaning with the help of maintenance. They will take them down wash and scrubb them and painted if needed, as I, food director, will dust around walls and corners Starting May 29th As of last week, 5-21-25, we changed our flour bin to the cambro bins which will be replaced everytime we restock and will be placed in dry storage. Black matter behind dishwasher will be resolved by scrubbing with limeaway and bleach to give it the white look starting Tuesday May 27th. OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. 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 02/11/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Flooring throughout the kitchen, specifically underneath and behind equipment/storage shelves, corners, areas near walls (cove base), areas around counter legs and equipment wheels – food debris/significant black matter; * Ceiling vents and surrounding ceiling areas, including dry storage area, dishwashing area, food prep areas and refrigeration units – significant build up of dust; * Wall behind refrigeration units and sides of the units – significant build up of dust; * Bottom shelf of two door freezer – build up of food debris; * Wall behind stove – drips of grease; * Drain under two sink counter – significant build up of black matter; * Exterior of food bin storing flour – significant food debris; * Interior of microwaves in kitchen and two kitchenettes – food splatter; * Wall behind dishwasher, under sink and above back splash – significant build up of black matter; and * Lower shelf under stand mixer – food debris/crumbs on foil lined pans. Other areas of concern included: * Uncovered garbage when not in use; * Colored cutting boards with worn finishes (potentially uncleanable); and * Commercial can opener blade with finish worn off. The areas of concern were observed and discussed with Staff 1 (Food Service Director) and discussed with Staff 2 (Executive Director) on 02/11/25. The findings were acknowledged. How I tend to correct this section is by: -Set a Monthly cleaning chart for maintnence to pressure wash our floors. We are mopping daily every night as it is in the daily check-off list. I myself or Whom the Diet aid or Executive Director, will be checking and making sure it is being done.(Will be completed 2/28/25) -We will also set a monthy checklist for Cleaning the ceiling vents and surrounding areas such as the dry storeage area, food prep area, and refridgerator area. Because of this issue there has been dust build upon the sides of the reachins. With this issue, I will be adding more to the weekly cleaning where cleaning the outside and wall areas are a must. Will be completed this weeks by (2/28/25). -We have a weekly deep cleaning list that says wiping down inside the 3 main reachins. We do this every week. I will be making sure it is being done and I will be the one who can mark off the checklist. (Will complete by Wednesday 2/26/25) -Our issue with wiping behind the stove walls, Cleaning the microwaves in kitchen and kitchennete and wiping under the mixer is on our Weekly Deep Cleaning checklist. We assign a section to a person and they get it done within that week period. What I will change is have a due date to make sure it is being done. (Complete by 2/28/25) -The drain under the 2-sink will be scrubbed once a month by myself to make sure we keep this up. I will use any cleaning chemical we have in out closet to use 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 ensure the kitchen was maintained in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 04/30/25 at 1218 pm, the kitchen was toured and the following was observed: a. The following areas were in need of cleaning: * The flooring had black matter and food splashes/spills around the kitchen, especially under the dishwashing area and the double-sink area; * The walls above the refrigerators and freezers, the ceilings, and the ceiling vents had a buildup of dust; * The exterior of the food bin storing flour had a buildup of food splatters/debris; * The wall behind the dishwasher, under the sink, and above the backsplash had a buildup of black matter; and * The walls and shelves in the dry storage area had food splashes. b. The following areas were in need of repair: * There was broken flooring material in the corner of the wall where the small desk/chair was; * A triangle-shaped piece of flooring was missing and the flooring was cracked at the wall joint to the left of the mop sink; * A section of wall between the refrigerator and the double-sink area had chipped paint, missing drywall, and missing baseboard material; * There was a gouge in the wall to the left of the dishwashing sink near a bottle of multisurface disinfectant; and * The walls around the mop sink had peeling paint and were chipped, the faucets were rusted, and the wall around the faucet appeared bubbled with water damage. During an interview at 12:18 pm on 04/30/25, Staff 1 (Food Director) stated she was the only staff in the kitchen available for cleaning. She stated she tried to maintain a log with weekly tasks but often fell behind due to other duties, and she couldn’t reach the upper walls and ceilings. She stated there was a maintenance staff responsible for completing kitchen repairs, but he “was usually at [another building] instead of here.” She confirmed there was no other staff assisting with kitchen cleaning or maintenance. The areas needing cleaning and repair were toured with Staff 3 (ED) on 04/30/25. She acknowledged the findings. Walls and shelves in dry storage was resolved by a new check out list both morning and night shift checks off at the end of there shift. check list if needed. Director will be more sturn on making sure they are doing there job well done. Walls in mop area will be resoulved by patching chipped piaint, whole and patched up with PVC panels. Pipes will be scrubbed and polish with a rust cleaner provided by maintetence starting Wednesday May 28th. All walls and corners with chipped paint, peeling paint and/or water damage will be resolved by patching and new paint on a day where both maintenance and food directorcan both work together done by the end of the month. 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 eviden”
“Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C240. Damaged floor will be fixed and patched like new. We will start every other month bringing in someone perfesaional to do a deep cleaning, wax and pollish corners and along the base board and in corners we cant reach starting sometime next week/end of month. 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 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. and bleach it so it shines. (Will be completed be Wednesday 2/26/25.) -Food Bins will be replaced with a new bin since we have lost the lid to one them with a better storeage so no debris can enter the bin. -Black debris around the dishwasher areas will be handled by adding to the daily cleaning checklist. We will be scrubbing all walls and backsplashes every shift. We will also be wipping under the sink to make sure no build up lingers. Will be completed 2/28/25 -We will be getting a new garbage can with a lid to replace our other one that’s by the coffee station. -Colored cutting boards have been replaced with newer ones. Alread completed on 2/20/25 -Commercial can opener, I have ordered a new one and will be replaced immediatley. (Being delivered as we speak. Delivery arrival is 2/27/25) For Z142 - 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, 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. 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:”
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Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations for food services. Findings include, but are not limited to: During the first revisit of the kitchen inspection of 02/11/25, conducted 04/30/25, administrative oversight to ensure adequate food services rendered in the facility was found to be ineffective based on failure to implement plan of correction and ensure adequate oversight to correct deficiencies. Refer to deficiencies in the report. Co240: A) what will be fixed about this problem is a new cleaning chart. A new updated cleaning chart will be placed starting today, May 23rd 2025. This will indicate scrubbing the floor with a scrubby broom instead of a mop head every night, every day. Walls above the fridges and freezer including the vents will be a monthly cleaning with the help of maintenance. They will take them down wash and scrubb them and painted if needed, as I, food director, will dust around walls and corners Starting May 29th As of last week, 5-21-25, we changed our flour bin to the cambro bins which will be replaced everytime we restock and will be placed in dry storage. Black matter behind dishwasher will be resolved by scrubbing with limeaway and bleach to give it the white look starting Tuesday May 27th. OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. 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 02/11/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Flooring throughout the kitchen, specifically underneath and behind equipment/storage shelves, corners, areas near walls (cove base), areas around counter legs and equipment wheels – food debris/significant black matter; * Ceiling vents and surrounding ceiling areas, including dry storage area, dishwashing area, food prep areas and refrigeration units – significant build up of dust; * Wall behind refrigeration units and sides of the units – significant build up of dust; * Bottom shelf of two door freezer – build up of food debris; * Wall behind stove – drips of grease; * Drain under two sink counter – significant build up of black matter; * Exterior of food bin storing flour – significant food debris; * Interior of microwaves in kitchen and two kitchenettes – food splatter; * Wall behind dishwasher, under sink and above back splash – significant build up of black matter; and * Lower shelf under stand mixer – food debris/crumbs on foil lined pans. Other areas of concern included: * Uncovered garbage when not in use; * Colored cutting boards with worn finishes (potentially uncleanable); and * Commercial can opener blade with finish worn off. The areas of concern were observed and discussed with Staff 1 (Food Service Director) and discussed with Staff 2 (Executive Director) on 02/11/25. The findings were acknowledged. How I tend to correct this section is by: -Set a Monthly cleaning chart for maintnence to pressure wash our floors. We are mopping daily every night as it is in the daily check-off list. I myself or Whom the Diet aid or Executive Director, will be checking and making sure it is being done.(Will be completed 2/28/25) -We will also set a monthy checklist for Cleaning the ceiling vents and surrounding areas such as the dry storeage area, food prep area, and refridgerator area. Because of this issue there has been dust build upon the sides of the reachins. With this issue, I will be adding more to the weekly cleaning where cleaning the outside and wall areas are a must. Will be completed this weeks by (2/28/25). -We have a weekly deep cleaning list that says wiping down inside the 3 main reachins. We do this every week. I will be making sure it is being done and I will be the one who can mark off the checklist. (Will complete by Wednesday 2/26/25) -Our issue with wiping behind the stove walls, Cleaning the microwaves in kitchen and kitchennete and wiping under the mixer is on our Weekly Deep Cleaning checklist. We assign a section to a person and they get it done within that week period. What I will change is have a due date to make sure it is being done. (Complete by 2/28/25) -The drain under the 2-sink will be scrubbed once a month by myself to make sure we keep this up. I will use any cleaning chemical we have in out closet to use 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 ensure the kitchen was maintained in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 04/30/25 at 1218 pm, the kitchen was toured and the following was observed: a. The following areas were in need of cleaning: * The flooring had black matter and food splashes/spills around the kitchen, especially under the dishwashing area and the double-sink area; * The walls above the refrigerators and freezers, the ceilings, and the ceiling vents had a buildup of dust; * The exterior of the food bin storing flour had a buildup of food splatters/debris; * The wall behind the dishwasher, under the sink, and above the backsplash had a buildup of black matter; and * The walls and shelves in the dry storage area had food splashes. b. The following areas were in need of repair: * There was broken flooring material in the corner of the wall where the small desk/chair was; * A triangle-shaped piece of flooring was missing and the flooring was cracked at the wall joint to the left of the mop sink; * A section of wall between the refrigerator and the double-sink area had chipped paint, missing drywall, and missing baseboard material; * There was a gouge in the wall to the left of the dishwashing sink near a bottle of multisurface disinfectant; and * The walls around the mop sink had peeling paint and were chipped, the faucets were rusted, and the wall around the faucet appeared bubbled with water damage. During an interview at 12:18 pm on 04/30/25, Staff 1 (Food Director) stated she was the only staff in the kitchen available for cleaning. She stated she tried to maintain a log with weekly tasks but often fell behind due to other duties, and she couldn’t reach the upper walls and ceilings. She stated there was a maintenance staff responsible for completing kitchen repairs, but he “was usually at [another building] instead of here.” She confirmed there was no other staff assisting with kitchen cleaning or maintenance. The areas needing cleaning and repair were toured with Staff 3 (ED) on 04/30/25. She acknowledged the findings. Walls and shelves in dry storage was resolved by a new check out list both morning and night shift checks off at the end of there shift. check list if needed. Director will be more sturn on making sure they are doing there job well done. Walls in mop area will be resoulved by patching chipped piaint, whole and patched up with PVC panels. Pipes will be scrubbed and polish with a rust cleaner provided by maintetence starting Wednesday May 28th. All walls and corners with chipped paint, peeling paint and/or water damage will be resolved by patching and new paint on a day where both maintenance and food directorcan both work together done by the end of the month. 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 eviden Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C240. Damaged floor will be fixed and patched like new. We will start every other month bringing in someone perfesaional to do a deep cleaning, wax and pollish corners and along the base board and in corners we cant reach starting sometime next week/end of month. 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 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. and bleach it so it shines. (Will be completed be Wednesday 2/26/25.) -Food Bins will be replaced with a new bin since we have lost the lid to one them with a better storeage so no debris can enter the bin. -Black debris around the dishwasher areas will be handled by adding to the daily cleaning checklist. We will be scrubbing all walls and backsplashes every shift. We will also be wipping under the sink to make sure no build up lingers. Will be completed 2/28/25 -We will be getting a new garbage can with a lid to replace our other one that’s by the coffee station. -Colored cutting boards have been replaced with newer ones. Alread completed on 2/20/25 -Commercial can opener, I have ordered a new one and will be replaced immediatley. (Being delivered as we speak. Delivery arrival is 2/27/25) For Z142 - 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, 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. 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:
2024-10-28Complaint InvestigationOR-cited · 5 findings
Plain-language summary
A complaint investigation conducted on October 28, 2024, substantiated that the facility failed to carry out medication and treatment orders as prescribed for four residents: one resident did not receive 29 doses of Metformin after it was discontinued without a physician order; another received a half dose of Alprazolam instead of the full prescribed dose; a third resident missed multiple doses of six different medications due to medication unavailability in July 2024; and a fourth resident missed 35 doses of Eliquis between March 5 and March 22, 2024. Staff were unable to explain the discontinuation of the first resident's medication, and the facility reported completing pharmacy training and planning medication technician training as corrective measures.
“Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: A review of Resident 5's signed physician orders dated 03/05/24 indicated the following: · Metformin 500mg "Take one tablet by mouth every day." A review of Resident 5's 03/01/24 - 03/31/24 MAR indicated the following: · Metformin (for type 2 diabetes) was discontinued on 03/06/24; · Resident 5 did not receive 29 doses of Metformin. No discontinue order was available or provided for Resident 5's Metformin. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) were unable explain why Resident 5's Metformin was discontinued. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors on 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: A review of Resident 3's signed physician orders dated 06/28/24 indicated: · Alprazolam 0.25 mg oral tablet; "Take 1 tab(s) oral Daily as needed for anxiety; panic disorder" start date of 10/12/23. A review of Resident 3's 06/01/24 - 06/30/24 MAR indicated: · 06/09/24 staff marked Alprazolam PRN as administered at 14:34. A review of Resident 3's 06/09/24 progress notes indicated: · Staff contacted Resident 3's spouse to get permission to administer Alprazolam PRN, Resident 3's spouse gave permission to administer a half dose of medication. Staff administered a half dose of Alprazolam. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) stated after the medication error was reported the nurse completed a one-on-one training with the med tech that was responsible for the error. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility nurse completed one on one training with the responsible med tech and a med tech training was conducted for physician orders and communicating with outside providers for clarification on orders. The facility staff conducted Consonus Pharmacy training on 10/28/24. Based on interview and record review, conducted during a site visit on 10/28/24, 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 signed physician orders dated 05/21/24 and 08/12/24 indicated: · Atorvastatin 80 mg tablet (for heart disease), Take 0.5 tablets by mouth daily; · Clopidogrel 75 mg tablet (for blood clots), Take 1 tablet by mouth daily; · Levetiracetam 250 mg tablet (for seizures), Take 1 tablet by mouth 2 times daily; · Levothyroxine 100mcg tablet (for thyroid), Take 1 tablet by mouth every morning; · Aspercreme Lidocaine 4% patch (for pain). Place 1 patch onto the skin daily. (apply for 12 hours then remove for 12 hours); and · Sertaline HCI 50 mg tablet (for depression and anxiety), Give 2 tablets orally in the morning, start date 02/21/24. A review of Resident 6's 07/01/24 - 07/31/24 MAR indicated: · 07/17/24 and 07/18/24, Resident 6 did not receive two doses of Atorvastatin 80mg, due to medication not available; · 07/12/24 - 07/16/24, Resident 6 did not receive four doses of Clopidogrel Bisul 75 mg, due to medication not available; · 07/07/24 - 07/09/24, Resident 6 did not receive four doses of Levetiracetam 250 mg, due to medication not available; · 07/28/24 - 07/29/24, Resident 6 did not receive two doses of Levothyroxine Sod 100 mcg, due to medication not available; · 07/14/24 - 07/16/24, Resident 6 did not receive three doses of Sertraline HCI 50 mg, due to medication not available; and · 07/01/24 - 07/02/24, Resident 6 did not receive two doses of Aspercreme pad Lid 4%, due to medication not available. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) all acknowledged Resident 6 missed several medications throughout July 2024. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors on 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment 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 02/26/24 indicated the following: · Apixaban (Eliquis) 5 mg for atrial fibrillation, to "Take ½ tablet by mouth twice daily for 8 days starting 02/26/24. On 03/05/24, resume Take 1 tablet by mouth every 12 hours." A review of Resident 4's 02/01/24 - 03/31/24 MARs indicated the following: · On 02/26/24 Resident 4's MAR was updated to reflect physician orders and 0.5 tab of Eliquis was administered for eight days. · From 03/05/24 - 03/22/24 Resident 4 missed 35 administrations of Eliquis. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) were unable explain why Resident 4's Eliquis did not start on 03/05/24 as ordered. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors by end of day 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: A review of Resident 5's signed physician orders dated 03/05/24 indicated the following: · Metformin 500mg "Take one tablet by mouth every day." A review of Resident 5's 03/01/24 - 03/31/24 MAR indicated the following: · Metformin (for type 2 diabetes) was discontinued on 03/06/24; · Resident 5 did not receive 29 doses of Metformin. No discontinue order was available or provided for Resident 5's Metformin. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) were unable explain why Resident 5's Metformin was discontinued. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors on 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed ”
“Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to consistently staff to meet or exceed the posted staffing plan 24 hours a day, seven days a week was substantiated. Findings include, but are not limited to: A review of the facility's posted staffing plan indicated the following: · Day Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor; · Swing Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor; and · Night Shift: One care staff on first floor, one care staff on second floor, two care staff on third floor and one med tech on shift. A review of facility's schedule for 10/22/24 - 10/28/24 indicated seven of the 21 shifts reviewed were staffed below the posted staffing plan. In an interview on 10/28/24, Staff 8 (Caregiver) stated the third floor has had to borrow staff from other floors due to not having enough staff to care for the residents on the third floor. On 10/28/24, the third-floor swing shift was observed to have two caregivers and one med tech, which was less than the posted staffing indicated. All other required elements of the Acuity Based Staffing Tool were in compliance. The facility failed to fully implement and update an acuity-based staffing tool. All other required elements of the Acuity Based Staffing Tool were in compliance. The findings were reviewed with Staff 1 (Executive Director) on 11/27/24. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to consistently staff to meet or exceed the posted staffing plan 24 hours a day, seven days a week was substantiated. Findings include, but are not limited to: A review of the facility's posted staffing plan indicated the following: · Day Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor; · Swing Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor; and · Night Shift: One care staff on first floor, one care staff on second floor, two care staff on third floor and one med tech on shift. A review of facility's schedule for 10/22/24 - 10/28/24 indicated seven of the 21 shifts reviewed were staffed below the posted staffing plan. In an interview on 10/28/24, Staff 8 (Caregiver) stated the third floor has had to borrow staff from other floors due to not having enough staff to care for the residents on the third floor. On 10/28/24, the third-floor swing shift was observed to have two caregivers and one med tech, which was less than the posted staffing indicated. All other required elements of the Acuity Based Staffing Tool were in compliance. The facility failed to fully implement and update an acuity-based staffing tool. All other required elements of the Acuity Based Staffing Tool were in compliance. The findings were reviewed with Staff 1 (Executive Director) on 11/27/24.”
“Based on observation and interview, conducted during a site visit on 10/28/24, the facility's failure to ensure all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair was substantiated. Findings include, but are not limited to: In an interview on 10/28/24, Staff 7 (Med tech) stated there used to be a push bar on the exit door to the first-floor courtyard but believed a resident had broken it and it was never fixed or replaced. The first-floor exit door to the courtyard was observed to be missing a push bar and screws were visible where the bar connected to the door. The exit sliding glass doors to patios on the second and third floors were observed to have locks that did not function. The facility failed to keep all equipment necessary for the health, safety, and comfort of the residents clean and in good repair. The findings were reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) on 10/28/24. Facility Verbal Plan of Correction: The Executive Director was to make maintenance aware of the door locks and missing push bar by 10/29/24 and would get them fixed. Based on observation and interview, conducted during a site visit on 10/28/24, the facility's failure to ensure all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair was substantiated. Findings include, but are not limited to: In an interview on 10/28/24, Staff 7 (Med tech) stated there used to be a push bar on the exit door to the first-floor courtyard but believed a resident had broken it and it was never fixed or replaced. The first-floor exit door to the courtyard was observed to be missing a push bar and screws were visible where the bar connected to the door. The exit sliding glass doors to patios on the second and third floors were observed to have locks that did not function. The facility failed to keep all equipment necessary for the health, safety, and comfort of the residents clean and in good repair. The findings were reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) on 10/28/24. Facility Verbal Plan of Correction: The Executive Director was to make maintenance aware of the door locks and missing push bar by 10/29/24 and would get them fixed.”
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Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: A review of Resident 5's signed physician orders dated 03/05/24 indicated the following: · Metformin 500mg "Take one tablet by mouth every day." A review of Resident 5's 03/01/24 - 03/31/24 MAR indicated the following: · Metformin (for type 2 diabetes) was discontinued on 03/06/24; · Resident 5 did not receive 29 doses of Metformin. No discontinue order was available or provided for Resident 5's Metformin. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) were unable explain why Resident 5's Metformin was discontinued. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors on 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: A review of Resident 3's signed physician orders dated 06/28/24 indicated: · Alprazolam 0.25 mg oral tablet; "Take 1 tab(s) oral Daily as needed for anxiety; panic disorder" start date of 10/12/23. A review of Resident 3's 06/01/24 - 06/30/24 MAR indicated: · 06/09/24 staff marked Alprazolam PRN as administered at 14:34. A review of Resident 3's 06/09/24 progress notes indicated: · Staff contacted Resident 3's spouse to get permission to administer Alprazolam PRN, Resident 3's spouse gave permission to administer a half dose of medication. Staff administered a half dose of Alprazolam. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) stated after the medication error was reported the nurse completed a one-on-one training with the med tech that was responsible for the error. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility nurse completed one on one training with the responsible med tech and a med tech training was conducted for physician orders and communicating with outside providers for clarification on orders. The facility staff conducted Consonus Pharmacy training on 10/28/24. Based on interview and record review, conducted during a site visit on 10/28/24, 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 signed physician orders dated 05/21/24 and 08/12/24 indicated: · Atorvastatin 80 mg tablet (for heart disease), Take 0.5 tablets by mouth daily; · Clopidogrel 75 mg tablet (for blood clots), Take 1 tablet by mouth daily; · Levetiracetam 250 mg tablet (for seizures), Take 1 tablet by mouth 2 times daily; · Levothyroxine 100mcg tablet (for thyroid), Take 1 tablet by mouth every morning; · Aspercreme Lidocaine 4% patch (for pain). Place 1 patch onto the skin daily. (apply for 12 hours then remove for 12 hours); and · Sertaline HCI 50 mg tablet (for depression and anxiety), Give 2 tablets orally in the morning, start date 02/21/24. A review of Resident 6's 07/01/24 - 07/31/24 MAR indicated: · 07/17/24 and 07/18/24, Resident 6 did not receive two doses of Atorvastatin 80mg, due to medication not available; · 07/12/24 - 07/16/24, Resident 6 did not receive four doses of Clopidogrel Bisul 75 mg, due to medication not available; · 07/07/24 - 07/09/24, Resident 6 did not receive four doses of Levetiracetam 250 mg, due to medication not available; · 07/28/24 - 07/29/24, Resident 6 did not receive two doses of Levothyroxine Sod 100 mcg, due to medication not available; · 07/14/24 - 07/16/24, Resident 6 did not receive three doses of Sertraline HCI 50 mg, due to medication not available; and · 07/01/24 - 07/02/24, Resident 6 did not receive two doses of Aspercreme pad Lid 4%, due to medication not available. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) all acknowledged Resident 6 missed several medications throughout July 2024. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors on 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment 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 02/26/24 indicated the following: · Apixaban (Eliquis) 5 mg for atrial fibrillation, to "Take ½ tablet by mouth twice daily for 8 days starting 02/26/24. On 03/05/24, resume Take 1 tablet by mouth every 12 hours." A review of Resident 4's 02/01/24 - 03/31/24 MARs indicated the following: · On 02/26/24 Resident 4's MAR was updated to reflect physician orders and 0.5 tab of Eliquis was administered for eight days. · From 03/05/24 - 03/22/24 Resident 4 missed 35 administrations of Eliquis. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) were unable explain why Resident 4's Eliquis did not start on 03/05/24 as ordered. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors by end of day 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: A review of Resident 5's signed physician orders dated 03/05/24 indicated the following: · Metformin 500mg "Take one tablet by mouth every day." A review of Resident 5's 03/01/24 - 03/31/24 MAR indicated the following: · Metformin (for type 2 diabetes) was discontinued on 03/06/24; · Resident 5 did not receive 29 doses of Metformin. No discontinue order was available or provided for Resident 5's Metformin. In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) were unable explain why Resident 5's Metformin was discontinued. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24. Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors on 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to consistently staff to meet or exceed the posted staffing plan 24 hours a day, seven days a week was substantiated. Findings include, but are not limited to: A review of the facility's posted staffing plan indicated the following: · Day Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor; · Swing Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor; and · Night Shift: One care staff on first floor, one care staff on second floor, two care staff on third floor and one med tech on shift. A review of facility's schedule for 10/22/24 - 10/28/24 indicated seven of the 21 shifts reviewed were staffed below the posted staffing plan. In an interview on 10/28/24, Staff 8 (Caregiver) stated the third floor has had to borrow staff from other floors due to not having enough staff to care for the residents on the third floor. On 10/28/24, the third-floor swing shift was observed to have two caregivers and one med tech, which was less than the posted staffing indicated. All other required elements of the Acuity Based Staffing Tool were in compliance. The facility failed to fully implement and update an acuity-based staffing tool. All other required elements of the Acuity Based Staffing Tool were in compliance. The findings were reviewed with Staff 1 (Executive Director) on 11/27/24. Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to consistently staff to meet or exceed the posted staffing plan 24 hours a day, seven days a week was substantiated. Findings include, but are not limited to: A review of the facility's posted staffing plan indicated the following: · Day Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor; · Swing Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor; and · Night Shift: One care staff on first floor, one care staff on second floor, two care staff on third floor and one med tech on shift. A review of facility's schedule for 10/22/24 - 10/28/24 indicated seven of the 21 shifts reviewed were staffed below the posted staffing plan. In an interview on 10/28/24, Staff 8 (Caregiver) stated the third floor has had to borrow staff from other floors due to not having enough staff to care for the residents on the third floor. On 10/28/24, the third-floor swing shift was observed to have two caregivers and one med tech, which was less than the posted staffing indicated. All other required elements of the Acuity Based Staffing Tool were in compliance. The facility failed to fully implement and update an acuity-based staffing tool. All other required elements of the Acuity Based Staffing Tool were in compliance. The findings were reviewed with Staff 1 (Executive Director) on 11/27/24. Based on observation and interview, conducted during a site visit on 10/28/24, the facility's failure to ensure all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair was substantiated. Findings include, but are not limited to: In an interview on 10/28/24, Staff 7 (Med tech) stated there used to be a push bar on the exit door to the first-floor courtyard but believed a resident had broken it and it was never fixed or replaced. The first-floor exit door to the courtyard was observed to be missing a push bar and screws were visible where the bar connected to the door. The exit sliding glass doors to patios on the second and third floors were observed to have locks that did not function. The facility failed to keep all equipment necessary for the health, safety, and comfort of the residents clean and in good repair. The findings were reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) on 10/28/24. Facility Verbal Plan of Correction: The Executive Director was to make maintenance aware of the door locks and missing push bar by 10/29/24 and would get them fixed. Based on observation and interview, conducted during a site visit on 10/28/24, the facility's failure to ensure all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair was substantiated. Findings include, but are not limited to: In an interview on 10/28/24, Staff 7 (Med tech) stated there used to be a push bar on the exit door to the first-floor courtyard but believed a resident had broken it and it was never fixed or replaced. The first-floor exit door to the courtyard was observed to be missing a push bar and screws were visible where the bar connected to the door. The exit sliding glass doors to patios on the second and third floors were observed to have locks that did not function. The facility failed to keep all equipment necessary for the health, safety, and comfort of the residents clean and in good repair. The findings were reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) on 10/28/24. Facility Verbal Plan of Correction: The Executive Director was to make maintenance aware of the door locks and missing push bar by 10/29/24 and would get them fixed.
2023-08-03Annual Compliance VisitOR-cited · 5 findings
Plain-language summary
A state kitchen inspection on August 3, 2023 found the facility's main kitchen did not meet food sanitation rules because it was not clean and in good repair—inspectors documented food spills, debris, dust, and dirt on floors, shelves, equipment, doors, and ceiling vents, along with missing or damaged equipment and structural damage to walls and door frames. The facility completed three follow-up inspections over the following months, and by February 15, 2024 was found to be in substantial compliance with the food sanitation and meals rules.
“The findings of the kitchen inspection, conducted 08/03/23, 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, Oregon Health Service Food Sanitation Rules and OARs 411 Division 57 for Memory Care Communities. The findings of the kitchen inspection, conducted 08/03/23, 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, Oregon Health Service Food Sanitation Rules and OARs 411 Division 57 for Memory Care Communities. The findings of the first revisit to the kitchen inspection of 08/03/23, conducted 10/27/23, 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 of 08/03/23, conducted 10/27/23, 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 08/03/23, conducted 12/07/23, 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 08/03/23, conducted 12/07/23, 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 third revisit to the kitchen inspection of 8/03/23, conducted 02/15/24, 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 third revisit to the kitchen inspection of 8/03/23, conducted 02/15/24, 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 and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 08/03/23 the first floor main kitchen, and second and third floor kitchenettes were inspected. The main kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dust, dirt, and black matter was observed on, inside, around or underneath the following: * Floor throughout the kitchen including the dry storage area; * Stainless steel upper and lower shelves throughout the kitchen; * Caulking above the one compartment sink backsplash; * Warewasher; * Toaster; * Hobart mixer; * Industrial can opener; * Stainless steel cabinets throughout the kitchen; * Entryway doors and door frames, door to mop closet, and door to dry storage area; * Ceiling vents throughout the kitchen; and * Mop sink. b. The following equipment was in need of repair: * Entryway door was missing a transition strip; * Mop closet was missing the right door; * Right corner flashing to the mop closet was off, it was located leaning against the wall in the storage closet; and * Exterior wall and door frame to the dry storage, interior and exterior doors, door frames and walls in the chemical storage closet, and wall above the three compartment sink had gouges and holes and were uncleanable. The need to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000, was discussed with Staff 1 (ED) and Staff 1 (Kitchen Manager) on 08/03/23. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 08/03/23 the first floor main kitchen, and second and third floor kitchenettes were inspected. The main kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dust, dirt, and black matter was observed on, inside, around or underneath the following: * Floor throughout the kitchen including the dry storage area; * Stainless steel upper and lower shelves throughout the kitchen; * Caulking above the one compartment sink backsplash; * Warewasher; * Toaster; * Hobart mixer; * Industrial can opener; * Stainless steel cabinets throughout the kitchen; * Entryway doors and door frames, door to mop closet, and door to dry storage area; * Ceiling vents throughout the kitchen; and * Mop sink. b. The following equipment was in need of repair: * Entryway door was missing a transition strip; * Mop closet was missing the right door; * Right corner flashing to the mop closet was off, it was located leaning against the wall in the storage closet; and * Exterior wall and door frame to the dry storage, interior and exterior doors, door frames and walls in the chemical storage closet, and wall above the three compartment sink had gouges and holes and were uncleanable. The need to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000, was discussed with Staff 1 (ED) and Staff 1 (Kitchen Manager) on 08/03/23. They acknowledged the findings. C240: 1. All areas of kitchen identified have been cleaned. All areas identified in need of maintenance have been fixed. 2. Audits to be conducted to maintain kitchen cleanliness. 3. Kitchen manager do conduct review of daily check list of cleaning schedule. Administrator or designee to conduct weekly rounds to assure cleanliness. Maintenance to conduct weekly rounds in kitchen to assure ongoing compliance of any needed maintenance repairs. 4. Weekly rounds to be initiated, documentation of these rounds to be audited monthly by Administrator or designee. C240:”
“Based on interview and record review, it was determined the facility failed to ensure documentation of current food handlers certificates for 2 of 3 staff (#s 3 and 4) whose duties included preparing food. Findings include, but are not limited to: The kitchen inspection including a review of training records was completed on 08/03/23. Staff 3 and 4 (Cooks), hired on 08/08/20 and 02/28/18 respectively, lacked documented evidence of current food handlers certificates. The need to ensure staff, whose duties included preparing food, had current food handlers certificates was discussed with Staff 1 (ED) and Staff 2 (Kitchen Manager) on 08/03/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure documentation of current food handlers certificates for 2 of 3 staff (#s 3 and 4) whose duties included preparing food. Findings include, but are not limited to: The kitchen inspection including a review of training records was completed on 08/03/23. Staff 3 and 4 (Cooks), hired on 08/08/20 and 02/28/18 respectively, lacked documented evidence of current food handlers certificates. The need to ensure staff, whose duties included preparing food, had current food handlers certificates was discussed with Staff 1 (ED) and Staff 2 (Kitchen Manager) on 08/03/23. They acknowledged the findings. C370: 1. BOM will identify and inform staff of pending expirations of certifications and monitor for completion for compliance. 2. Audits to be conducted by BOM bi-weekly 3. Administrator or designee to conduct monthly review of audit. 4. Documentation of audits to be completed monthly. C370:”
“Based on interview and observation, 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. Based on interview and observation, 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. Refer to C 240 Refer to C 240 Based on interview and observation, 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 interview and observation, 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 C240 and C370. 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 C240 and C370. Z142: Refer to C240 and C370 Z142: Refer to C240 and C370 Based on observation and interview, 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 and interview, 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 C 240 Refer to C 240 Based on observation and interview, 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 and interview, 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.”
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The findings of the kitchen inspection, conducted 08/03/23, 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, Oregon Health Service Food Sanitation Rules and OARs 411 Division 57 for Memory Care Communities. The findings of the kitchen inspection, conducted 08/03/23, 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, Oregon Health Service Food Sanitation Rules and OARs 411 Division 57 for Memory Care Communities. The findings of the first revisit to the kitchen inspection of 08/03/23, conducted 10/27/23, 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 of 08/03/23, conducted 10/27/23, 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 08/03/23, conducted 12/07/23, 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 08/03/23, conducted 12/07/23, 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 third revisit to the kitchen inspection of 8/03/23, conducted 02/15/24, 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 third revisit to the kitchen inspection of 8/03/23, conducted 02/15/24, 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 and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 08/03/23 the first floor main kitchen, and second and third floor kitchenettes were inspected. The main kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dust, dirt, and black matter was observed on, inside, around or underneath the following: * Floor throughout the kitchen including the dry storage area; * Stainless steel upper and lower shelves throughout the kitchen; * Caulking above the one compartment sink backsplash; * Warewasher; * Toaster; * Hobart mixer; * Industrial can opener; * Stainless steel cabinets throughout the kitchen; * Entryway doors and door frames, door to mop closet, and door to dry storage area; * Ceiling vents throughout the kitchen; and * Mop sink. b. The following equipment was in need of repair: * Entryway door was missing a transition strip; * Mop closet was missing the right door; * Right corner flashing to the mop closet was off, it was located leaning against the wall in the storage closet; and * Exterior wall and door frame to the dry storage, interior and exterior doors, door frames and walls in the chemical storage closet, and wall above the three compartment sink had gouges and holes and were uncleanable. The need to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000, was discussed with Staff 1 (ED) and Staff 1 (Kitchen Manager) on 08/03/23. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 08/03/23 the first floor main kitchen, and second and third floor kitchenettes were inspected. The main kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dust, dirt, and black matter was observed on, inside, around or underneath the following: * Floor throughout the kitchen including the dry storage area; * Stainless steel upper and lower shelves throughout the kitchen; * Caulking above the one compartment sink backsplash; * Warewasher; * Toaster; * Hobart mixer; * Industrial can opener; * Stainless steel cabinets throughout the kitchen; * Entryway doors and door frames, door to mop closet, and door to dry storage area; * Ceiling vents throughout the kitchen; and * Mop sink. b. The following equipment was in need of repair: * Entryway door was missing a transition strip; * Mop closet was missing the right door; * Right corner flashing to the mop closet was off, it was located leaning against the wall in the storage closet; and * Exterior wall and door frame to the dry storage, interior and exterior doors, door frames and walls in the chemical storage closet, and wall above the three compartment sink had gouges and holes and were uncleanable. The need to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000, was discussed with Staff 1 (ED) and Staff 1 (Kitchen Manager) on 08/03/23. They acknowledged the findings. C240: 1. All areas of kitchen identified have been cleaned. All areas identified in need of maintenance have been fixed. 2. Audits to be conducted to maintain kitchen cleanliness. 3. Kitchen manager do conduct review of daily check list of cleaning schedule. Administrator or designee to conduct weekly rounds to assure cleanliness. Maintenance to conduct weekly rounds in kitchen to assure ongoing compliance of any needed maintenance repairs. 4. Weekly rounds to be initiated, documentation of these rounds to be audited monthly by Administrator or designee. C240: Based on interview and record review, it was determined the facility failed to ensure documentation of current food handlers certificates for 2 of 3 staff (#s 3 and 4) whose duties included preparing food. Findings include, but are not limited to: The kitchen inspection including a review of training records was completed on 08/03/23. Staff 3 and 4 (Cooks), hired on 08/08/20 and 02/28/18 respectively, lacked documented evidence of current food handlers certificates. The need to ensure staff, whose duties included preparing food, had current food handlers certificates was discussed with Staff 1 (ED) and Staff 2 (Kitchen Manager) on 08/03/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure documentation of current food handlers certificates for 2 of 3 staff (#s 3 and 4) whose duties included preparing food. Findings include, but are not limited to: The kitchen inspection including a review of training records was completed on 08/03/23. Staff 3 and 4 (Cooks), hired on 08/08/20 and 02/28/18 respectively, lacked documented evidence of current food handlers certificates. The need to ensure staff, whose duties included preparing food, had current food handlers certificates was discussed with Staff 1 (ED) and Staff 2 (Kitchen Manager) on 08/03/23. They acknowledged the findings. C370: 1. BOM will identify and inform staff of pending expirations of certifications and monitor for completion for compliance. 2. Audits to be conducted by BOM bi-weekly 3. Administrator or designee to conduct monthly review of audit. 4. Documentation of audits to be completed monthly. C370: Based on interview and observation, 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. Based on interview and observation, 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. Refer to C 240 Refer to C 240 Based on interview and observation, 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 interview and observation, 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 C240 and C370. 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 C240 and C370. Z142: Refer to C240 and C370 Z142: Refer to C240 and C370 Based on observation and interview, 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 and interview, 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 C 240 Refer to C 240 Based on observation and interview, 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 and interview, 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.
2023-08-02Complaint InvestigationOR-cited · 4 findings
Plain-language summary
A complaint investigation conducted August 2-3, 2023 found the facility failed to keep its Acuity Based Staffing Tool current and accurate, with 21 of 42 residents incorrectly listed as requiring zero care hours, and the executive director acknowledged the data had not been updated. The investigation also found the facility failed to document that it had observed and evaluated a medication technician's ability to safely administer medications unsupervised before allowing the person to work in that role starting in April 2023. The facility provided verbal plans to correct both issues, including updating the staffing tool by end of day August 3, 2023, and completing competency documentation for all staff under its new resident care coordinator.
“The findings of the on-site investigation, conducted 08/02/2023 through 08/03/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 LPN: Licensed Practical Nurse MT: Medication 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 The findings of the on-site investigation, conducted 08/02/2023 through 08/03/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 LPN: Licensed Practical Nurse MT: Medication 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”
“Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the ODHS ABST website on 08/01/2023 indicated this facility had 42 of 42 residents entered into the ABST. Twenty-one of the 42 residents were listed as requiring zero care hours. In an interview on 08/02/23, Staff 1 (Executive Director) stated the facility does use the ODHS ABST, and s/he had entered all of the residents into the tool but had not updated any of their information in it. S/he stated the RN, RCC and ED were intending to spend the next couple of days getting the information cleaned up, updated and corrected within the tool, but that it was not currently updated or accurate. The facility failed to fully implement and update an Acuity Based Staffing Tool. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: The RCC, RN and ED had been working on 08/02/23and 08/03/23 on updating all of the information in the tool and correcting data entry errors. The ABST will be completed and up-to-date by the end of day 08/03/23. Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the ODHS ABST website on 08/01/2023 indicated this facility had 42 of 42 residents entered into the ABST. Twenty-one of the 42 residents were listed as requiring zero care hours. In an interview on 08/02/23, Staff 1 (Executive Director) stated the facility does use the ODHS ABST, and s/he had entered all of the residents into the tool but had not updated any of their information in it. S/he stated the RN, RCC and ED were intending to spend the next couple of days getting the information cleaned up, updated and corrected within the tool, but that it was not currently updated or accurate. The facility failed to fully implement and update an Acuity Based Staffing Tool. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: The RCC, RN and ED had been working on 08/02/23and 08/03/23 on updating all of the information in the tool and correcting data entry errors. The ABST will be completed and up-to-date by the end of day 08/03/23.”
“Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 1 sampled staff members (# 7). Findings include, but are not limited to: A review of Staff 7 (Med Tech) demonstrated competencies and staff list with hire dates indicated the following: · Staff 7 was hired on 04/06/23 and demonstrated competencies were signed off as completed with RCC on 07/05/23. A review of staff schedule, dated July 2023, indicated Staff 7 was working in the capacity of a Med Tech prior to completion of his/her demonstrated competencies. In an interview on 08/03/23, Staff 1 (Executive Director) stated that when Staff 7 was hired there was a different RCC that worked at the facility and completed the training but failed to complete the paperwork. The facility failed ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: The facility has hired a new RCC and s/he is responsible for completing the paperwork and ensuring it is completed timely. All new staff are assigned a staff member to shadow and then are evaluated for competency. Since the RCC started s/he has reviewed staff files and has completed training and paperwork of all employees that did not have it completed already. Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 1 sampled staff members (# 7). Findings include, but are not limited to: A review of Staff 7 (Med Tech) demonstrated competencies and staff list with hire dates indicated the following: · Staff 7 was hired on 04/06/23 and demonstrated competencies were signed off as completed with RCC on 07/05/23. A review of staff schedule, dated July 2023, indicated Staff 7 was working in the capacity of a Med Tech prior to completion of his/her demonstrated competencies. In an interview on 08/03/23, Staff 1 (Executive Director) stated that when Staff 7 was hired there was a different RCC that worked at the facility and completed the training but failed to complete the paperwork. The facility failed ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: The facility has hired a new RCC and s/he is responsible for completing the paperwork and ensuring it is completed timely. All new staff are assigned a staff member to shadow and then are evaluated for competency. Since the RCC started s/he has reviewed staff files and has completed training and paperwork of all employees that did not have it completed already.”
“Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: In an interview on 08/03/23, Staff 1 (Executive Director) stated the activities portion in resident service plans are the individualized activity plans. A review of Resident 2's service plan, dated 06/05/23, did not address the following: · Physical abilities or limitations in participating in activities; · Adaptations necessary for the resident to participate; and · Identification of activities for behavioral interventions. The facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: Each residents' service plan will be reviewed to ensure the activities portion is compliant with the rule. As the facility is in the process of migrating systems to Point Click Care Staff 1 will ensure that the information is current and accurate within their system as the migration occurs. Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: In an interview on 08/03/23, Staff 1 (Executive Director) stated the activities portion in resident service plans are the individualized activity plans. A review of Resident 2's service plan, dated 06/05/23, did not address the following: · Physical abilities or limitations in participating in activities; · Adaptations necessary for the resident to participate; and · Identification of activities for behavioral interventions. The facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: Each residents' service plan will be reviewed to ensure the activities portion is compliant with the rule. As the facility is in the process of migrating systems to Point Click Care Staff 1 will ensure that the information is current and accurate within their system as the migration occurs.”
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The findings of the on-site investigation, conducted 08/02/2023 through 08/03/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 LPN: Licensed Practical Nurse MT: Medication 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 The findings of the on-site investigation, conducted 08/02/2023 through 08/03/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 LPN: Licensed Practical Nurse MT: Medication 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 Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the ODHS ABST website on 08/01/2023 indicated this facility had 42 of 42 residents entered into the ABST. Twenty-one of the 42 residents were listed as requiring zero care hours. In an interview on 08/02/23, Staff 1 (Executive Director) stated the facility does use the ODHS ABST, and s/he had entered all of the residents into the tool but had not updated any of their information in it. S/he stated the RN, RCC and ED were intending to spend the next couple of days getting the information cleaned up, updated and corrected within the tool, but that it was not currently updated or accurate. The facility failed to fully implement and update an Acuity Based Staffing Tool. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: The RCC, RN and ED had been working on 08/02/23and 08/03/23 on updating all of the information in the tool and correcting data entry errors. The ABST will be completed and up-to-date by the end of day 08/03/23. Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the ODHS ABST website on 08/01/2023 indicated this facility had 42 of 42 residents entered into the ABST. Twenty-one of the 42 residents were listed as requiring zero care hours. In an interview on 08/02/23, Staff 1 (Executive Director) stated the facility does use the ODHS ABST, and s/he had entered all of the residents into the tool but had not updated any of their information in it. S/he stated the RN, RCC and ED were intending to spend the next couple of days getting the information cleaned up, updated and corrected within the tool, but that it was not currently updated or accurate. The facility failed to fully implement and update an Acuity Based Staffing Tool. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: The RCC, RN and ED had been working on 08/02/23and 08/03/23 on updating all of the information in the tool and correcting data entry errors. The ABST will be completed and up-to-date by the end of day 08/03/23. Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 1 sampled staff members (# 7). Findings include, but are not limited to: A review of Staff 7 (Med Tech) demonstrated competencies and staff list with hire dates indicated the following: · Staff 7 was hired on 04/06/23 and demonstrated competencies were signed off as completed with RCC on 07/05/23. A review of staff schedule, dated July 2023, indicated Staff 7 was working in the capacity of a Med Tech prior to completion of his/her demonstrated competencies. In an interview on 08/03/23, Staff 1 (Executive Director) stated that when Staff 7 was hired there was a different RCC that worked at the facility and completed the training but failed to complete the paperwork. The facility failed ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: The facility has hired a new RCC and s/he is responsible for completing the paperwork and ensuring it is completed timely. All new staff are assigned a staff member to shadow and then are evaluated for competency. Since the RCC started s/he has reviewed staff files and has completed training and paperwork of all employees that did not have it completed already. Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 1 sampled staff members (# 7). Findings include, but are not limited to: A review of Staff 7 (Med Tech) demonstrated competencies and staff list with hire dates indicated the following: · Staff 7 was hired on 04/06/23 and demonstrated competencies were signed off as completed with RCC on 07/05/23. A review of staff schedule, dated July 2023, indicated Staff 7 was working in the capacity of a Med Tech prior to completion of his/her demonstrated competencies. In an interview on 08/03/23, Staff 1 (Executive Director) stated that when Staff 7 was hired there was a different RCC that worked at the facility and completed the training but failed to complete the paperwork. The facility failed ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: The facility has hired a new RCC and s/he is responsible for completing the paperwork and ensuring it is completed timely. All new staff are assigned a staff member to shadow and then are evaluated for competency. Since the RCC started s/he has reviewed staff files and has completed training and paperwork of all employees that did not have it completed already. Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: In an interview on 08/03/23, Staff 1 (Executive Director) stated the activities portion in resident service plans are the individualized activity plans. A review of Resident 2's service plan, dated 06/05/23, did not address the following: · Physical abilities or limitations in participating in activities; · Adaptations necessary for the resident to participate; and · Identification of activities for behavioral interventions. The facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: Each residents' service plan will be reviewed to ensure the activities portion is compliant with the rule. As the facility is in the process of migrating systems to Point Click Care Staff 1 will ensure that the information is current and accurate within their system as the migration occurs. Based on interview and record review, conducted during a site visit on 08/02/23-08/03/23, it was confirmed the facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: In an interview on 08/03/23, Staff 1 (Executive Director) stated the activities portion in resident service plans are the individualized activity plans. A review of Resident 2's service plan, dated 06/05/23, did not address the following: · Physical abilities or limitations in participating in activities; · Adaptations necessary for the resident to participate; and · Identification of activities for behavioral interventions. The facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/03/23. Verbal plan of correction: Each residents' service plan will be reviewed to ensure the activities portion is compliant with the rule. As the facility is in the process of migrating systems to Point Click Care Staff 1 will ensure that the information is current and accurate within their system as the migration occurs.
1 older inspection from 2022 are not shown above.
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