Print Inspection: KIT003034

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on observations, interviews, and record review, it was determined, the facility failed to ensure there was an effective method in place to respond and resolve resident complaints related to food/meal service. Findings include but are not limited to: On 03/03/25 at 9:30 am, food complaints and resident council minutes were reviewed. The following was identified: *January’s minutes noted residents complained of running out of items they liked such as cereal, silverware, cups and glasses; *February’s minutes noted residents were having trouble getting things cut up per their request/care plan and that some residents “get the impression the kitchen staff does not take their concerns seriously and just dismiss them entirely as change is very slow to come;” and *On 02/16/25 residents noted lunch was “cold” and of poor quality. On 03/03/25 at 10:45 am, Resident 1, Resident Council President, was interviewed and stated the following: *Food was always/mostly cold and never “hot”; *Meat was often tough/dry and hard to eat; *Residents did not like the menus; *Quality of the food was not acceptable; *Menu items would change without notification; *Room trays were often not what was ordered or not cut up per resident need; and *The residents did not feel heard related to on-going food concerns. During the lunch meal on 03/03/25 from 12:00 to 12:45pm 13 residents were observed eating in the dining room. Eleven residents were interviewed regarding the food. Seven of the 11 indicated some or all of the following: *Meals are “always” cold; and *Meat was often tough and dry; and *Disliked the “Grove” menus; and *Disliked the couscous. Three of the residents stated the lunch the day before was “gross”. One of the residents commented that many times the food “inedible.” Majority of residents interviewed indicated they did not have adequate input into menu choices. During the lunch observation on 03/03/25, test trays were requested. The macaroni and cheese was observed at 112 degrees and tasted luke warm. Broccoli was observed at 103 degrees and tasted cold. Soup was observed at 109 degrees and tasted cold. Toasted garlic bread was observed at 100 degrees and tasted cold. Roasted chicken breast was observed at 117 degrees and tasted luke warm and was noted to taste dry. A cheeseburger patty was noted at 137 degrees and tasted warm and the meat was dry. The test trays were noted to be not palatable. During an interview on 03/03/05, at 1:15 pm, Staff 2 (Food Service Director) stated the following: *Meal delivery to the rooms had recently changed to help with cold food concerns; *Changed food prepared in main kitchen to improve consistency and quality; *Food was being delivered to the south dining room in tin foil and saran wrap; *Insulated carts were not used in delivery. During an interview on 03/03/05 at 3:00pm, Staff 1 (Administrator), Staff 2 and Staff 3 (Executive Director) acknowledged the on-going concerns related to food quality and temperature from the residents. On 04/04/25 at 1:30 pm Resident 2 was interviewed. The resident stated they needed their food cut up related to missing/pulled teeth and had communicated it to facility staff. Resident 2 stated they were not receiving cut up foods. Resident #2 service plan was reviewed and did not indicate need for food cut up. The facility had a list of residents who requested food cut up in the dining room posted for staff. Resident #2 was not on the list. Residents interviewed continue to feel the food service at facility was not adequate. Observations during meal service validated unpalatable temperatures for many food items. The facility has not effectively responded to or resolved concerns/complaints regarding meal services.

A)South Kitchen and Memory kitchenettes areas of note added to kitchen cleaning task sheet, staff training was completed to ensure cleaniness of idenified areas. B)Maintance to repair areas of note listed in Statement of deficencys C)Proper coverage of food items with proper dating, Food to be disposed of within 5 days. D)A thermometer was placed in all refridgerators. Tempature logs implemented in kitchenettes to log and ensure temp is maintaned at or below 41*. This is to be montiored x1 weekly for 3 months Administrator or Designee E) Single serve items not stored in closed containers F) Aprons were provided to staff to use while serving meals to resident to prevent comtaimnation from care tasks to meal service. G) Beard nets & Jewelry addressed H) Temperature to be monitored by culinary director or designee to monitor x3 a week for 3 months and as needed. I) Separate food services meeting implemented to ensure feedback on quality of meals, temperature, accuracy of orders, menu input and any other resident’s needs, monthly. A resident satisfaction survey was implemented. All areas of concern will be looked at x1 weekly for two monthes than once monthly and as needed

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair, in a sanitary manner, and ensure meals were palatable in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the south kitchen and memory care kitchenettes on 03/03/25 from 9:30 am through 2:30 pm and the Main kitchen on 03/04/25 from 9:30 am thru 2:30 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: South Kitchen: * Floors under/behind/between equipment; * Ceiling Vents; * Sides of stove/grill; * Metal utility carts; * Non metal utility carts; * Table top and large mixers; * Blender base; * Flooring around entry/exit doors to kitchen/service area; * Flooring around corners/edges in serving area; * Edges of shelving on racks in walk in cooler; * Freezer floor and threshold from cooler to freezer; * Green food delivery carts; * Microwave in dining room; * Juice machine in dining room; * Industrial can opener and housing; and * Tall movable metal rack. MC unit 2: * Reach in larger refrigerator; * Metal service equipment (not used); and * Microwave. Main Kitchen area: * Floors corners, edges; * Floors in walk in cooler under metal racks; * Racks in dry storage; * Metal can rack; * Microwave; * Walls/floors under dish washing area; and * Industrial can opener and housing. b. The following areas were in need of repair: * South serving area with sections of the wall with damage/exposed drywall. * South reach in freezer had large accumulation of ice. * Ceiling section near hood with cracked/peeling paint/previous water damage. * Missing cove base in sections of door thresholds in south kitchen. * Convection oven not operational in south kitchen. * Main kitchen bakery prep table was separated and pulling away from the wall c. Food items observed stored in reach in freezer were uncovered. Items found in coolers/refrigerators were not dated when opened or prepared. Food items found that were past manufactures use by dates. Facility prepared food found past 7 days. Ice cream in Memory care unit 1 found in reach in freezer that was not frozen. d. Activities area refrigerator contained food items that were opened and not dated. Multiple packages of dry good foods were found stored in cupboards/cabinets that were not closed and open to potential contamination. Refrigerator storing resident food did not have a thermometer to ensure food was stored at or below 41 degrees as required. e. Reach in refrigerators in both unit kitchenettes were noted above 41 degrees. There was not a system in place for staff to monitor refrigerator temperatures to ensure food was stored at appropriate temperatures. Staff 1 and 2 acknowledged food was not stored at appropriate temperatures and would need to be discarded. e. Single service utensils and paper plates stored in dry storage open to potential contamination. f. Care staff assisting residents with meal service were not wearing aprons or protective outer clothing to prevent potential contamination from care tasks to meal service tasks. g. Staff member washing dishes did not have facial hair restrained as required. h. Multiple residents during meal observations complained that often food temperatures seemed cold. A test tray received at 12;00 pm noted multiple meal items were not palatable. Mac and cheese was observed at 112 degrees and tasted luke warm. Broccoli was observed at 103 degrees and tasted cold. Soup was observed at 109 degrees and tasted cold. Toasted garlic bread was observed at 100 degrees and tasted cold. Roasted chicken breast was observed at 117 degrees and tasted luke warm and was noted to taste dry. Cheeseburger patty was noted at 137 degrees and the meat was dry. i. Cook serving the meal was observed to have multiple bracelets on during meals service, which is not allowed per code. On 03/03/25 Food Service Director and Staff 3 (Executive director) toured areas with surveyor and acknowledged the areas identified. On 03/03/25 at 2:00 pm, surveyor discussed test tray findings with Staff 2, Staff 1 and Staff 3. Who acknowledged the findings and no additional information was provided.

1) The Culinary Director reassessed and ordered more needed items. 2) Resident service plan and Dietary cut up list updated to be reflective of resident’s new needs. 3) Training provided to cooks and servers on 3/17/25, New plate warmers implemented to ensure correct heating temperature. 4) The Separate food services meeting implemented to ensure feedback on quality of meals, temperature, accuracy of orders, menu input and any other resident’s needs, monthly. A resident satisfaction survey was implemented. 5) Transporting food, is now done in a heat containing cart. Temperature audit x3 weekly for one month and ongoing as needed. The Administrator and Culinary Director will be responsible for overseeing this.

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:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Refer to C154 and C240

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: