Sherwood Pines Residential Care.

“Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the main kitchen and food storage areas on 01/07/26 at 11:15 am through 1:00 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Interior of drawers storing clean equipment; * Interior of cabinets storing food and/or equipment; * Top of reach-in refrigerators/freezers; and * Sponge used to clean dishes. b. The following areas were found in need of repair: * Multiple cabinets observed with edges and spots noted with porous wood exposed; and * Section of caulking behind the sink with damage and in need of replacement. c. Multiple items in reach-in refrigerators found with food items not dated when opened. d. Multiple potentially hazardous food items found in refrigerators that were past the manufacturer’s use by date and should have been discarded. e. Resident-specific food items were stored in refrigerators without resident identifiers or open/prepared dates. f. Whole shell egg cartons stored above ready to eat foods (milk cartons) posing a risk for cross contamination. g. Different raw meat products (beef/pork/ground meats) were stored in the same bin/storage space causing potential for cross contamination of the packages. h. A bag of shredded cheese was found stored open, exposing ready to eat food to possible contamination. i. Reach-in refrigerator near entry to kitchen did not have an internal thermometer to accurately monitor cold food storage temperatures. Staff were relying on the display temperature for monitoring. The temperature displayed was the temperature setting, not the internal temperature of the refrigerator. j. Staff were taking and recording the temperature of the hot food entrées only. Facility did not have a system for monitoring side dish or cold food temperatures for resident foods. Food temperature logs were reviewed, and multiple days were missing. k. Multiple food items were found stored in the pantry on the floor. l. A baking pan was noted to be heavily worn with large amount of baked on carbon debris and in need of replacement. A non-stick pan was noted to have multiple scratches where protective coating was worn/removed/chipped and in need of replacement. An ice cream scoop was worn with protective coating removed and needed replaced. Surveyor toured areas with Staff 2 (Cook/RCC) who acknowledged areas in need of correction. On 01/13/26 at approximately 1:00 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator), and she acknowledged the areas in need of correction. OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:”

“Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. 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, conducted during a site visit on 05/30/24, it was confirmed the facility failed to ensure the implementation of services for 3 of 4 sampled residents (#1's, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: Compliance Specialist (CS) observed the following on 05/30/24; · Residents 3 and 4 were in the dining room eating lunch at 12:38pm · At 5:50 pm Resident 1, Resident 3, and Resident 4 were up in the dining room eating dinner, · 5 staff were present in the facility and supervising dinner service, · Staff 2 (CG/Shower aide) was getting Resident 2's dinner cooled down to assist with feeding in his/her room. In an interview on 05/30/24, Staff 1 (ED) stated the following: · Showers were documented in the EMAR, · Nobody was auditing the showers lately to make sure they were getting documented, · The bath aide was in from 12pm-8pm to do showers, · Staff were feeding the residents, · There was one resident that got fed in bed and another 3 residents that were supervised. In an interview on 05/30/24, Staff 3 (CG/MT) stated the following: · We supervised three of the residents in the dining room, · Resident 2 was fed in his/her room, · "They always get fed. No concerns about them not getting fed", · " Showers get done when we have a shower aide [here]". In an interview with Resident 2 on 05/30/24, s/he stated the following: · "I get three meals a day if I want them" , · "They always help me get up to eat my meals", · "I had breakfast this morning" A review of Resident 1, Resident 2, Resident 3, and Resident 4's service plans and shower sheets for 05/01/24 through 05/31/24, indicated the following: * All three residents' service plans show baths needed at least twice per week, * Resident 1's only documented showers were on 05/18/24 and 05/25/24, * Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24, * Resident 4's only documented showers were on 05/18/24 and 05/25/24, * Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024. The findings were reviewed with and acknowledged by Staff 1 on 05/30/24. It was confirmed the facility failed to ensure the implementation of services. Plan of correction: Facility is considering moving the shower aide shift from 7am-3pm instead of 12pm-8pm. Frequent auditing will be done by management to ensure that staff are completing and documenting showers or any refusals. Based on observation, interview, and record review, conducted during a site visit on 05/30/24, it was confirmed the facility failed to ensure the implementation of services for 3 of 4 sampled residents (#1's, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: Compliance Specialist (CS) observed the following on 05/30/24; · Residents 3 and 4 were in the dining room eating lunch at 12:38pm · At 5:50 pm Resident 1, Resident 3, and Resident 4 were up in the dining room eating dinner, · 5 staff were present in the facility and supervising dinner service, · Staff 2 (CG/Shower aide) was getting Resident 2's dinner cooled down to assist with feeding in his/her room. In an interview on 05/30/24, Staff 1 (ED) stated the following: · Showers were documented in the EMAR, · Nobody was auditing the showers lately to make sure they were getting documented, · The bath aide was in from 12pm-8pm to do showers, · Staff were feeding the residents, · There was one resident that got fed in bed and another 3 residents that were supervised. In an interview on 05/30/24, Staff 3 (CG/MT) stated the following: · We supervised three of the residents in the dining room, · Resident 2 was fed in his/her room, · "They always get fed. No concerns about them not getting fed", · " Showers get done when we have a shower aide [here]". In an interview with Resident 2 on 05/30/24, s/he stated the following: · "I get three meals a day if I want them" , · "They always help me get up to eat my meals", · "I had breakfast this morning" A review of Resident 1, Resident 2, Resident 3, and Resident 4's service plans and shower sheets for 05/01/24 through 05/31/24, indicated the following: * All three residents' service plans show baths needed at least twice per week, * Resident 1's only documented showers were on 05/18/24 and 05/25/24, * Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24, * Resident 4's only documented showers were on 05/18/24 and 05/25/24, * Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024. The findings were reviewed with and acknowledged by Staff 1 on 05/30/24. It was confirmed the facility failed to ensure the implementation of services. Plan of correction: Facility is considering moving the shower aide shift from 7am-3pm instead of 12pm-8pm. Frequent auditing will be done by management to ensure that staff are completing and documenting showers or any refusals.”

“Based on observation, interview and record review, conducted during a site visit on 05/30/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: In an interview on 05/30/24, Staff 1 (Executive Director) stated the current census was 15 residents. Resident 5 moved in two days ago, and there was a resident that passed away, but the ABST had not been updated yet. Staff 1 stated staff were universal workers with additional tasks of cooking, serving food, housekeeping, activities, etc. A review of the facility's ABST and resident roster on 05/30/24, indicated the following: * There was 15 residents listed on the roster. * Resident 5 who moved in on 05/28/24 was not listed on the ABST. * On day shifts, 3.35 caregivers were needed; for swing shifts 3.19 caregivers were needed; and for night shift, 1.25 caregivers were needed. * Ten residents' ABST profiles had not been updated since 10/04/23. A review of the facility's posted staffing plan indicated the following: * Day shift 7am-3:15pm: one CG,  one MT; * Swing shift 3pm-11:15pm: one CG, one MT; * Noc shift 11pm-7:15am: one CG, one MT; * Activities 10am-6pm; and * Bath aide 12pm-8pm. A review of the facility's staff schedules, dated April 2024 and May 2024,  indicated the facility was staffing per their posted staffing plan. In an interview on 05/30/24, Staff 4 (CG/Activities) stated: "I do activities and help out wherever needs help". Compliance Specialist observed the following: * Day and swing shifts had a MT, a CG, an activities staff member, and a shower aide working. * At 12:04pm, the Staff 4 (Activities) was assisting with other caregiving duties such as transfering and assisting residents to the dining room for lunch and assisting with eating. * At 5:50pm, the Staff 2 (shower aide) was assisting with meals/feeding. A review of Resident 1, 2, and 4s'  service plans, dated 03/13/24, 03/26/24, 04/18/24, respectively, and shower sheets from 05/01/24-05/31/24, indicated the following: * All three residents' service plans show baths needed at least twice per week, * Resident 1's only documented showers were on 05/18/24 and 05/25/24, * Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24, * Resident 4's only documented showers were on 05/18/24 and 05/25/24, * Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024. On 05/30/24, findings were reviewed with and acknowledged by Staff 1. It was confirmed the facility failed to fully implement and update an ABST. Based on observation, interview and record review, conducted during a site visit on 05/30/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: In an interview on 05/30/24, Staff 1 (Executive Director) stated the current census was 15 residents. Resident 5 moved in two days ago, and there was a resident that passed away, but the ABST had not been updated yet. Staff 1 stated staff were universal workers with additional tasks of cooking, serving food, housekeeping, activities, etc. A review of the facility's ABST and resident roster on 05/30/24, indicated the following: * There was 15 residents listed on the roster. * Resident 5 who moved in on 05/28/24 was not listed on the ABST. * On day shifts, 3.35 caregivers were needed; for swing shifts 3.19 caregivers were needed; and for night shift, 1.25 caregivers were needed. * Ten residents' ABST profiles had not been updated since 10/04/23. A review of the facility's posted staffing plan indicated the following: * Day shift 7am-3:15pm: one CG,  one MT; * Swing shift 3pm-11:15pm: one CG, one MT; * Noc shift 11pm-7:15am: one CG, one MT; * Activities 10am-6pm; and * Bath aide 12pm-8pm. A review of the facility's staff schedules, dated April 2024 and May 2024,  indicated the facility was staffing per their posted staffing plan. In an interview on 05/30/24, Staff 4 (CG/Activities) stated: "I do activities and help out wherever needs help". Compliance Specialist observed the following: * Day and swing shifts had a MT, a CG, an activities staff member, and a shower aide working. * At 12:04pm, the Staff 4 (Activities) was assisting with other caregiving duties such as transfering and assisting residents to the dining room for lunch and assisting with eating. * At 5:50pm, the Staff 2 (shower aide) was assisting with meals/feeding. A review of Resident 1, 2, and 4s'  service plans, dated 03/13/24, 03/26/24, 04/18/24, respectively, and shower sheets from 05/01/24-05/31/24, indicated the following: * All three residents' service plans show baths needed at least twice per week, * Resident 1's only documented showers were on 05/18/24 and 05/25/24, * Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24, * Resident 4's only documented showers were on 05/18/24 and 05/25/24, * Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024. On 05/30/24, findings were reviewed with and acknowledged by Staff 1. It was confirmed the facility failed to fully implement and update an ABST.”

“The findings of the kitchen inspection, conducted 02/07/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 02/07/24, 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.”