Evergreen Memory Care Community

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 Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the facility main kitchen and the four unit kitchenettes occurred on 08/07/25 from 11:00am thru 1:30 pm and identified 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:

* All unit kitchenette cabinets under the sink with black debris buildup
* Kitchenette corner cabinets in multiple units

b. The following areas needed repair:

* All unit kitchenette cabinets under the sink with significant water damage to cabinets, piping with black debris buildup and/or evidence of water leakage.
* Microwave in Rockies unit observed with burn damage and multiple unsmooth/non cleanable areas and was in need of replacement.
* Pipe entering/exiting main kitchen ceiling with gaps around piping

c. Main hand wash sink in main kitchen area did not have a splash guard to prevent potential contamination. Clean dishes and a toaster were observed stored right next to sink. Another sink in the back of the kitchen had rags/clothes/debris stored in the sink bowl/basin area rendering it unusable. Staff 2 (Dining Services Director) acknowledged the sink in the back of the kitchen was not used very often by staff.

At 1:00 pm, surveyor reviewed identified areas with Staff 1 (Administrator). Staff 1 acknowledged areas needing 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:

The findings of the kitchen inspection, conducted 08/05/24, 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. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
The findings of the revisit to the kitchen inspection of 08/05/24, conducted 10/04/24, 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, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the main facility kitchen and the memory care unit kitchenettes on 08/05/24 from 10:30 am through 2:00 pm revealed the following deficient practices: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:* Fan above reach in fridge cages and blades;* Reach in refrigerator by beverage area in kitchen;* Industrial can opener blade;* Stainless steel shelving in baking/prep area;* Ceiling of microwave;* Reach in refrigerator in Rockies unit;* Toasters in units;* Lazy Susan cabinets in units;* Kitchenette floors in units; and * Table bases in Cascades unit.b. The following areas needed repair:* Caulking in ware washing area with black matter debris buildup;* Cabinets under microwave in units with shelving with exposed pressed/porous wood making non-cleanable surfaces; and * Reach in refrigerator in kitchen by beverage station reading 50 degrees during survey.c. Kitchen staff member observed to handle dirty dishes and reach into garbage disposal and handle lemons with the same gloves that they then handled clean dishes. No hand hygiene step was observed when going from a dirty task to a clean task as required. d. Thermometer in a reach in refrigerator holding resident beverages, multiple condiments, whipped topping and a pasta salad for evening meal was observed to be at 50 degrees. The thermometer was located in the door at the warmest portion of the fridge. Surveyor moved thermometer to the back/coldest part of the fridge and rechecked the temperature which dropped to 46 degrees but still above the required 41 degrees for cold storage. Review of refrigerator temperature logs revealed multiple days in May and July that the same fridge had been noted to be above 41 degrees and at times at 50 degrees. No evidence was found that the facility identified the incorrect and unsafe storage temperature of the fridge and made appropriate corrective actions to ensure food/beverages were being stored at the appropriate temperatures. e. Multiple small black ants were observed crawling on the floor around the small reach in refrigerator in Cascades unit. The ants were observed to crawl in/out of the broken seals in the floor/wall cove base.In an interview on 08/05/24 at 1:45 pm, Staff 1 (Executive director) and Staff 2 (Dining Services Manager) were informed of concerns found. Both staff 1 and 2 acknowledged areas in need of correction. Staff 2 was asked about the refrigerator temperatures and indicated whenever they checked the temperature it was at 41 degrees or below as required but indicated it was first thing in the morning and that the other cook checked the temperature in the afternoon. Staff 1 was unaware that the refrigerator was not effectively holding temperatures at 41 degrees or below and acknowledged there was no evidence that the appropriate interventions were put in place when temperatures were documented above the 41 degrees. Staff 1 indicated they would have maintenance look at the fridge and see if it could be adjusted to be cooler and that anything potentially hazardous would be discarded. If the current fridge could not maintain temperature, it would be repaired or replaced.

Based on observations, interviews 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.

The findings of the re-licensure survey, conducted 07/10/23 through 07/12/23, are documented in this report. The survey 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 07/12/23, conducted 11/13/23 through 11/14/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (#2) who was recently admitted to the facility. Findings include, but are not limited to:Resident 2 was admitted to the facility in 06/2023. The move-in evaluation, completed on 06/13/23, failed to address the following required elements:* Spiritual, cultural preferences and traditions;* Mental Health issues including: presence of depression, thought disorders or behavioral or mood problems; history of treatment; and effective non-drug interventions;* Pain: non-pharmaceutical interventions; * Complex medication regimen;* History of dehydration; and* Elopement risk or history. The need to ensure all required elements were addressed in the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/11/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided a written description of who shall provide the services and what, when, how, and how often the services shall be provided for 1 of 5 sampled residents (#5) whose service plans were reviewed. Findings include, but are not limited to:Resident 5 was admitted to facility in 06/2022 with diagnoses including dementia and repeated falls.The current service plan dated 05/14/23 and Interim Service Plans (ISP's) from 04/11/23 to 07/01/23 were reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:* Level of assistance required for transfers and toileting;* Modified diet requirements; and* Use of side rails, including safety checks.The need to ensure service plans were completed quarterly, were reflective of residents' current needs and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Coordinator/LPN) on 07/11/23 at 2:05 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3, 4, and 5's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.On 07/12/23 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/ LPN), and Staff 13 (Regional RN). They acknowledged the findings.

2. Resident 5 was admitted to the facility in 06/2022 with diagnoses including dementia and repeated falls.Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/14/23, and progress notes dated 04/01/23 through 07/07/23 were completed.The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and communication of the determined actions or interventions to staff on all shifts:* 04/11/23 - Fall out of bed with head injury;* 06/17/23 - Fall out of wheelchair; and* 06/27/23 - Dietary change to pureed diet.The need to ensure short-term changes of condition had actions or interventions determined documented in the resident record and were communicated to staff on all shifts was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Coordinator/LPN) on 07/11/23. They acknowledged the findings, and no additional documentation was provided.
Based on observation, interview, and record review, it was determined the facility failed to determine, document, and communicate resident-specific actions or interventions needed for 2 of 5 sampled residents (#s 2 and 5) who experienced changes of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 06/2023 with diagnoses including Alzheimer's disease.During the acuity interview on 07/10/23, Resident 2 was identified as having recently experienced a "rapid decline." Staff 3 (Resident Care Coordinator) and Staff 11 (Med Tech MC) both reported s/he was able to walk independently, feed him/herself, and interact with staff when s/he was admitted to the facility, and in a short period of time s/he became bedbound, non-responsive, and unable to eat.The resident's clinical record was reviewed, staff were interviewed, and observations were made.Interviews with Staff 8 (Care Partner MC), Staff 17 (Care Partner MC), and Staff 11 (Med Tech MC) on 07/10/23, 07/11/23, and 07/12/23 confirmed the information about Resident 2 presented in the acuity interview.Between 07/10/23 and 07/12/23 the resident was observed to be in bed during the entire survey. Staff were observed attempting to feed him/her on 07/11/23, but s/he was not responsive and did not eat anything.There was no documented evidence in the resident's clinical record of his/her recent decline or instructions to staff about changes in his/her ADL care needs.The need for actions or interventions to be determined, documented, and communicated with all staff was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/11/23 and 07/12/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN in a timely manner for 2 of 3 sampled residents (#s 1 and 2) who experienced significant changes. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 06/2023, already on hospice, with diagnoses including Alzheimer's disease.During the acuity interview on 07/10/23, Resident 2 was identified as having recently experienced a rapid decline.A review of the resident's clinical record and interviews with staff identified the following:* When the resident was admitted to the facility in 06/2023, s/he was ambulating and eating independently and spent time each day walking around the unit.* The resident experienced a fall on 06/27/23.* Staff reported after the fall the resident stopped ambulating, was unable to feed him/herself, and became bedbound and "mostly" non-responsive.* Hospice indicated to staff the resident was in a "pre-transition" phase.There was no documented evidence the RN had completed a significant change of condition assessment which documented findings, resident status, and interventions made as a result of the assessment, and the service plan was not updated.The RN was unavailable for interview during the survey.The need to ensure a significant change of condition assessment was completed by an RN within 48 hours was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN). They acknowledged the findings.2. Resident 1 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease.A review of the resident's record identified the following weights:* 04/01/23: 181.8 lbs.;* 06/01/23: 176 lbs.; and* 07/01/23: 165 lbs.Between 04/01/23 and 07/01/23 the resident lost 16.8 lbs., or 9.24% of his/her total body weight, in three months. This was a severe weight loss and constituted a significant change of condition.Between 06/01/23 and 07/01/23 the resident lost 11 lbs., or 6.25% of his/her body weight, in one month. This was a severe weight loss and constituted a significant change of condition.A review of the resident's progress notes revealed a significant change of condition assessment was completed by the RN on 07/07/23, over a week after the weight loss was triggered.The facility's RN was unavailable for interview during survey.The need to ensure significant change assessments were completed by the RN in a timely manner was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/12/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure staff were informed of new interventions, adjust the service plan if necessary, and ensure reporting protocols were in place for 1 of 3 sampled residents (# 2) who received outside services. Findings include, but are not limited to:Resident 2 was admitted to the facility in 06/2023 with a diagnoses of Alzheimer's Disease with behavioral disturbances. Resident 2's outside provider notes, dated 06/14/23 through 07/10/23, were reviewed, and the following changes in pain and new skin concerns were identified:* 06/22/23 Certified Nurses Aide (CNA): "lethargy, lower ability to ambulate, new behavior/grabbing"; * 06/28/23 CNA: "agitated during cares. Sm red area on bottom, two small red areas on L forearm, R knee-small";* 06/29/23 CNA: "Ribcage looks swollen - R side more swollen than Left. [Resident 2] stated nothing was painful. Eyes-skin near inner R eye red - and L outer red";* 06/30/23 CNA: "Declined taking off shirt and asked this CNA to stop when this CNA was washing stomach-chest. Patient was guarding [his/her] chest. Ribcage on both sides - swollen and painful. Discharge out of eyes - painful when gently wiping eyes - asked to "Not do that";* 6/30/23 RN: "orders for eye cream to follow and schedule tylenol";* 07/03/23 CNA: "declined a new shirt guarding chest and pulled shirt down. Feet cold and toes look purple. Lips look blue. Eyes - skin - red and painful when wiping. Painful when R arm touched. Seeing things and talking about tweezers that [s/he] needs to take to the cows. Lower ribcage swollen";* 07/05/23 CNA: "new-Red area on R elbow and slightly swollen. Ribcage swollen. Toes appear slightly purple and lips appear blue. Painful when dressing and rolling";* 07/06/23 CNA: "redness on R elbow - R elbow painful to touch. Skin around eyes - red"; and* 07/07/23 RN: "painful to right elbow when touched, some swelling noted. Fidgeting with eyes closed."There was no documented evidence staff were informed of new interventions and the service plan was adjusted to ensure continuity of care. The need to coordinate care with outside providers, inform staff of new interventions, adjust the service plan when needed, and have reporting protocols in place was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/12/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medications administered by the facility were set-up and documented by the same person who administered the medications for 1 of 5 sampled residents (#2). Findings include, but are not limited to:Resident 2 was admitted to the facility in 06/2023 with diagnoses including Alzheimer's disease with behavioral disturbances.The resident's clinical record was reviewed and the following was identified:A progress note dated 06/15/23 stated: "[The resident] did not like me, and would not take the medicine from me. I got care partner to give it to [him/her]."In an interview on 07/11/23, Staff 1 (Administrator) indicated she was "surprised" the med tech would have a care partner administer medication to a resident. She stated she would investigate and speak with the med tech.The need for all medications to be administered by trained med techs and for medications to be administered and documented by the same person was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the ABST (Acuity Based Staffing Tool) was updated at least quarterly and following changes of condition, to determine appropriate staffing levels to address activities of daily living and other tasks related to care for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5). Findings include, but are not limited to: Observations, interviews, and review of clinical records, including service plans for Residents 1, 2, 3, 4, and 5, revealed the facility's ABST tool was not updated quarterly and when there was a significant change of condition to reflect the residents' care needs, in order to ensure the ABST was accurately determining the needed staffing levels.On 07/12/23 the need to ensure the ABST tool was updated to determine appropriate staffing levels to address activities of daily living and other tasks related to care was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/ LPN), and Staff 13 (Regional RN). They acknowledged the findings.

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 361.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C252, C260, C 262, C270, C 280, C 290, and C 301.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3, 4, and 5's current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status and preferences and needs of the resident. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Coordinator/LPN) on 07/11/23. They acknowledged the findings.

The findings of the kitchen inspection, conducted 11/15/22, 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 revisit to the kitchen inspection of 11/15/22, conducted 1/19/23, 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 11/15/22, conducted 4/26/23, 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, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 11/15/22 revealed splatters, spills, drips, and debris noted on: - Can opener blade and casing; - Stand mixer; - Food Processor; - Interior and exterior of the microwave; - Walls in food preparation area; - Interior of reach in freezer; - Food packages and containers in dry food storage area;, - Dishes and cookware stored on open shelving and racks; - Open stainless steel shelving and metal rack shelving; - Top of black reach in refrigerator and juice machine, - Ceiling vent above black reach in refrigerator; - Plastic knife case hanging on the wall; - Bakery racks; - Front grate of the ice machine; - Underneath shelving and equipment; - Floor of the walk in refrigerator; - Dishwashing area including flooring, walls, and equipment; and - Radio.* The stand mixer blade was noted to have the finished chipped off. * Cutting boards were deeply scored and flaking off pieces.* Open packages and dented cans were noted in the dry food storage area.* Dish washing racks were stored on the floor. Visible debris was noted on the clean side of the dish machine.* The rinse cycle thermometer on the dish machine was not operating. * Staff were using a mixture of bleach and dish soap for sanitizing. There was no evidence of testing the solution to ensure between 50 and 110 parts per million. When tested, it was above 200 parts per million. * Staff were observed to not change gloves between tasks while handling ready to eat foods.Observations of the kitchenettes on 11/14/22 revealed:* Splatters, spills, drips, and debris noted on: - Interior and exterior of cupboards and drawers and walls; - Outer surfaces of garbage cans and hampers; - Interiors of mini-refrigerators; - Interior and exterior of microwaves;and - Flooring and cove base.* Undated and unlabeled storage bags of cookies and rolls were noted in a drawer.* Food wrapped in aluminum was observed left in a microwave.* The mini-refrigerator/freezers were noted to have frost build up in the freezers and damage to the shelving in the refrigerators.Staff 2 (Dietary Manger) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings.The areas in need of cleaning and repair were reviewed with Staff 1 (Administrator). She acknowledged the findings.

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 1/19/23 revealed splatters, spills, drips, dust and debris noted on: - Dishwashing Equipment; and - Fire sprinkler heads.* White cutting board on steam table was found to be deeply scored and stained.* Dish washing rack was observed stored on the floor. * Hole in the wall exposing electrical and piping found on the back left wall by the baking rack.*The rinse cycle thermometer on the dish machine was not operating correctly. The rinse dial was reading 170 and did not move. The wash cycle thermometer did not quite get to 180. The dish machine temperature logs were reviewed and revealed multiple readings that were not at the required 180 F for sanitation. Staff 2 (Dietary Manager) stated the process when dish machine was not operating correctly was to utilize the 3 compartment sink method. Staff 2 validated s/he was not notified when temperatures were not reaching 180 and could not verify that a 3 compartment sink method was utilized under those circumstances. Staff 2 utilized an instant read digital thermometer to validate rinse temperature was at 181.3 F after 4 runs of machine. Kitchen staff stated that the temperature gages "never work right". Staff 2 did validate that the dish machine had been serviced multiple times that month and there were still problems with the temperature gauges. Staff 2 (Dietary Manger) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings.Observations of the kitchenettes on 1/19/23 revealed:* Splatters, spills, drips, and debris noted on: - Interior and exterior of cupboards and drawers; - Interior and exterior of microwave; and - Flooring and molding.* One of the mini-refrigerator/freezer had damage to the shelving making it a non cleanable surface. One of four microwaves were found to be damaged making it a non cleanable surface.* Two coffee containers were found with scoops stored inside and touching the coffee grounds.* Under the sinks of all kitchenettes had a large cut out area in the cabinet. The underneath of these cabinets were dirty and had exposed particle board. Pipes were dirty with potential leaks on the pipes. One sink had a strong odor and visible standing fluid in a basin under the pipe. All areas had items stored under the sink that could be potentially contaminated by dripping grey water from the sink (toasters, coffee makers). *Multiple cabinet interiors had exposed particle board in various areas.The areas in need of cleaning and repair were reviewed with Staff 1 (Administrator). She acknowledged the findings.

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.

Based on observation, record review 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.