Russellville Park West Memory Care

Residential Care Facility
20 SE 103RD AVENUE, PORTLAND, OR 97216

Facility Information

Facility ID 50R360
Status Active
County Multnomah
Licensed Beds 20
Phone 5032545900
Administrator WILLIAM GRADY
Active Date May 1, 2009
Owner Russellville III, LLC
1022 SW SALMON ST, STE 450
PORTLAND OR 97205
Funding Private Pay
Services:

No special services listed

4
Total Surveys
19
Total Deficiencies
0
Abuse Violations
11
Licensing Violations
0
Notices

Violations

Licensing: 00300035-AP-335074
Licensing: 00229370-AP-187467
Licensing: 00229950-AP-187924
Licensing: 00212452-AP-172012
Licensing: 00007855AP-005814
Licensing: CO17001
Licensing: BC132917
Licensing: BC120177
Licensing: BC116536
Licensing: 00300770-AP-254054
Licensing: OR0001844900

Survey History

Survey KIT005989

1 Deficiencies
Date: 7/31/2025
Type: Kitchen

Citations: 1

Citation #1: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
t Visit: 7/31/2025 | Not Corrected
1 Visit: 10/16/2025 | Not Corrected
Regulation:
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).
Inspection Findings:
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 07/31/25 at 11:00 am, the facility main kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following:

* Knobs and face of oven and grill;
* Floor underneath stove and grill;
* Multiple floor drains;
* Caulking behind hand wash and two-compartment sink;
* Wall and pipes under two-compartment sink;
* Lids of food bins in dry storage room and food prep area;
* Multiple walls throughout;
* Three-shelf rolling serving carts;
* Flooring and drain in beverage area; and
* Floor of dessert fridge.

b. The following areas needed repair:

* Peeling paint on wall behind sprayer in dish machine area;
* Door and jamb to storage room had scraped paint;
* Dessert fridge had pooled water on the interior floor. A baking sheet with a towel was placed on the top shelf to catch water dripping from the interior vent; and
* Peeling paint in the beverage area next to the right entrance door.

c. Observations of food service in the MCC on 07/31/25 at 12:10 pm revealed the following:

* Care staff were plating and serving resident’s meals without the use of a protective barrier over potentially contaminated clothing; and
* Care staff touched food with bare hands while plating it for the residents.

The areas that required cleaning and repair in the facility main kitchen were observed and discussed with Staff 2 (Executive Chef) on 07/31/25 at 11:55 am. He acknowledged the findings.

The need to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules was reviewed with Staff 1 (General Manager) during the exit interview on 07/31/25. The findings were acknowledged.

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:
Plan of Correction:
Rule Violated: OAR 411-054-0030 (1)(a); OAR 333-150-0000
A full deep cleaning of the kitchen was completed on August 1, 2025, addressing all areas identified during the inspection. This included thorough cleaning of appliances, walls, floors, sinks, food bins, rolling carts, and the dessert fridge. The baking sheet and towel found inside the dessert fridge were immediately removed and discarded.
The maintenance team was assigned the following repairs:
• Repainting walls with peeling paint,
• Repairing and sealing the damaged door jamb,
• Repairing or replacing the dessert fridge to resolve the issue of pooled water.
A revised cleaning schedule outlining specific daily, weekly, and monthly responsibilities was implemented effective August 1st, 2025. A cleaning checklist and log are now required to be completed daily and verified by the Executive Chef.
Monthly environmental inspections will be conducted by the Administrator or designee to ensure sustained compliance.
Responsible Parties:
• Executive Chef: Oversees kitchen cleanliness, ensures staff compliance, and verifies daily cleaning logs.
• General Manager: Conducts weekly walkthroughs, monitors implementation of the plan, and ensures monthly inspections are completed and systems sustained.
• Maintenance Director: Responsible for the timely completion of all kitchen-related repairs and ongoing facility maintenance.


• On August 1, 2025, all MCC care staff were immediately re-educated on food safety protocols, including the mandatory use of protective barriers (aprons/gowns) when handling or serving food.
• Staff were instructed that bare-hand contact with ready-to-eat food is strictly prohibited and must be replaced with utensil use or single-use gloves.
• Supervisors conducted direct observation and coaching during meal service the following day to reinforce correct practices.
• Protective disposable aprons were stocked and made easily accessible in the MC dining area.
• Effective August 2, 2025, a visual checklist for food safety and PPE use during meal service was posted and implemented in the MC.
• A new “Meal Service Compliance Spot Check” log was introduced, requiring supervisors to observe and document adherence to safe food practices during randomly selected meal periods.
• Procedures and language updated to clarify that any direct hand contact with food or failure to use protective gear will result in immediate coaching and, if repeated, disciplinary action.
MCC Supervisor – Ensures staff wear protective gear and avoid bare-hand contact during service.
• General Manager – Reviews compliance data and ensures system is sustained.
• Administrator – Ensures quarterly training occurs and that spot checks are evaluated for trends and follow-through.

Survey LWEL

3 Deficiencies
Date: 5/21/2024
Type: State Licensure, Other

Citations: 4

Citation #1: C0000 - Comment

Visit History:
1 Visit: 5/21/2024 | Not Corrected
2 Visit: 7/26/2024 | Not Corrected
3 Visit: 9/25/2024 | Not Corrected
Inspection Findings:
The findings of the kitchen inspection, conducted 05/21/24, 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 and OARs 411 Division 57 for Memory Care Communities.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.

The findings of the first re-visit to the kitchen inspection of 05/21/24, conducted 07/26/24, 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 second revisit to the kitchen inspection of 05/21/24, conducted 09/25/24, 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.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
1 Visit: 5/21/2024 | Not Corrected
2 Visit: 7/26/2024 | Not Corrected
3 Visit: 9/25/2024 | Corrected: 9/9/2024
Inspection Findings:
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 05/21/24 at 11:15 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, drips, debris, grease, black/brown matter and/or dust was observed on the following areas: * Shelves below steam table - food debris/spills;* Ice cream freezer - spills on bottom and shelves;* Upright refrigerator - floor with food debris;* Walk in freezer floor - food debris;* Floor under grill/stove - food debris;* Shelves above grill/stove including foil lined shelf with grease and food debris;* Knobs and front of grill/stove - drips and spills;* Interior shelves of refrigerator located on the steam table - plastic worn off, rusted, food debris on bottom shelf and black/brown debris/matter on interior door seals;* Interior of microwave - food debris splatter;* Sides of deep fat fryer, grill/stove - grease/food drips;* Grill top blackened surface and edges;* Upper and lower shelves of prep counters - food debris;* Lids of food storage bins - food debris, sticky;* Ice machine interior - black/pink matter;* Tray under food slicer - food debris/crumbs;* Wall behind sprayer hose in dishwashing area - black matter build up;* Top of dishwasher - debris;* Refrigerator in beverage service area - spills/drips;* Electrical cord of microwave - heavy build up of dust near clean dishes;* Toaster (automatic) - heavily soiled with crumbs;* Four-slice toaster - front covered with debris/drips/spills;* Exterior of convection oven - spills/grease;* Waffle iron - burnt debris sitting on paper lined tray with dried on drips/spills; and* Sprinkler head next to oven/grill hood - heavily accumulation of dust. b. Improper food storage: * Walk in freezer - two stacks of boxes on floor;* Ice cream freezer - one tub of ice cream uncovered;* Walk in refrigerator - shell eggs stored on top of pan of cooked rice which was covered with plastic wrap; * Unlabeled/undated bags of cooked pasta, cut fruit, multiple containers of food items; * Uncovered cooked meat on rolling cart;* Uncovered containers of seasonings/herb on grill shelf;* Refrigerator located on steam table - uncovered/unlabeled food items (salad/asparagus);* Food storage bins containing sugar, flour and panko crumbs had scoops in the products;* Container of uncovered lemon slices was stored on beverage station counter; and* Open/uncovered container of ketchup and closed container of garlic butter were stored on steam table counter. c. Items needing repaired: * Uncovered ceiling lights in dry food storage and entrance to kitchen; and* Drawer fronts on prep counter. d. Other findings: * Two uncovered garbage cans stored near the steam table and * Staff not wearing beard restraints. The findings were discussed and observed by Staff 2 (Chef) and discussed with Staff 3 (General Manager) on 05/21/24. The findings were acknowledged.
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 OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to:On 07/26/24 at 10:45 am, the facility main kitchen located in the assisted living which serviced the memory care community was observed to need cleaning in the following areas: a. Food spills, splatters, drips, debris, grease, black/brown matter and/or dust was observed on the following areas: * Shelves below steam table;* Upright refrigerator;* Floor under grill/stove;* Knobs and front of grill/stove had buildup of drips and spills;* Sides of deep fryer and grill/stove;* Upper and lower shelves of prep counters;* Wall behind sprayer hose in dishwashing area had black matter build up above and below the counter;* Exterior of convection oven - spills/grease;* Vulcan oven interior had a build up of food debris;* Ice cream freezer had old ice cream packaging beneath open ice cream containers; and* Food storage bins containing sugar, flour and panko crumbs had scoops in the products.b. Areas needing repair in the assisted living kitchen: * Ceiling lights and tiles above the food prep and food service areas were damaged and/or stained; * Drawer fronts on prep counter were broken;* Refrigerator located beneath the steam table had damaged door seals and doors had exposed refrigeration insulation;* The Blodgett convection oven was inoperable;* Holes in the wall surrounding pipes inside the beverage sink cabinets; and* Holes in the wall surrounding pipes in the dish machine area.c. Areas needing repair in the memory care kitchenette:* A cabinet door below the steam table had a broken hinge which prevented the cabinet door to open and close properly. d. Infection control:* Two uncovered garbage cans stored near the steam table; and * Staff not wearing beard restraints. A tour of the kitchen was completed and the findings were discussed with Staff 2 (Chef) and Staff 3 (General Manager) on 07/26/24 at 12:30 pm. The findings were acknowledged.
C-240 - Following the visit on July 26, 2024, the Food and Beverage Team has cleaned / corrected each cited item to address the rule violation affecting all residents. General Manager has reviewed the communities Food Handling Policy with all Food and Beverage Members. A Sanitation Inspection Form and task list has been established for the community and will be completed on a daily basis. This will be reviewed with the Food and Beverage Team and review of the findings and any corrective action plans will be addressed. The areas needing repair have been completed by the Facilities Maintenance Team and we have contacted vendors regarding the repair/ replacement costs of the inoperable Blodgett oven. The General Manager is responsible to see that all corrections have been completed and monitored.
Plan of Correction:
C-240 - Following the visit on May 21st, 2024, the Food and Beverage Team has cleaned / corrected each cited item to address the rule violation affecting all residents. General Manager has reviewed the communities Food Handling Policy with all Food and Beverage Members. A Sanitation Inspection Form has been established for the community and will be completed on a weekly basis. The weekly Sanitation Inspection Form will be reviewed by the Chef, who will review the findings and any corrective action plans with the General Manager / designee at the weekly 1:1 GM/Chef meeting and documented using the established meeting agenda template. The General Manager is responsible to see that the corrections are completed and monitored. C-240 - Following the visit on July 26, 2024, the Food and Beverage Team has cleaned / corrected each cited item to address the rule violation affecting all residents. General Manager has reviewed the communities Food Handling Policy with all Food and Beverage Members. A Sanitation Inspection Form and task list has been established for the community and will be completed on a daily basis. This will be reviewed with the Food and Beverage Team and review of the findings and any corrective action plans will be addressed. The areas needing repair have been completed by the Facilities Maintenance Team and we have contacted vendors regarding the repair/ replacement costs of the inoperable Blodgett oven. The General Manager is responsible to see that all corrections have been completed and monitored.

Citation #3: C0455 - Inspections and Investigation: Insp Interval

Visit History:
2 Visit: 7/26/2024 | Not Corrected
3 Visit: 9/25/2024 | Corrected: 9/9/2024
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure their kitchen relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.
Plan of Correction:
C-240 - Following the visit on July 26, 2024, the Food and Beverage Team has cleaned / corrected each cited item to address the rule violation affecting all residents. General Manager has reviewed the communities Food Handling Policy with all Food and Beverage Members. A Sanitation Inspection Form and task list has been established for the community and will be completed on a daily basis. This will be reviewed with the Food and Beverage Team and review of the findings and any corrective action plans will be addressed. The areas needing repair have been completed by the Facilities Maintenance Team and we have contacted vendors regarding the repair/ replacement costs of the inoperable Blodgett oven. The General Manager is responsible to see that all corrections have been completed and monitored.

Citation #4: Z0142 - Administration Compliance

Visit History:
1 Visit: 5/21/2024 | Not Corrected
2 Visit: 7/26/2024 | Not Corrected
3 Visit: 9/25/2024 | Corrected: 9/9/2024
Inspection Findings:
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.
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 POC
Plan of Correction:
C-240 - Following the visit on May 21st, 2024, the Food and Beverage Team has cleaned / corrected each cited item to address the rule violation affecting all residents. General Manager has reviewed the communities Food Handling Policy with all Food and Beverage Members. A Sanitation Inspection Form has been established for the community and will be completed on a weekly basis. The weekly Sanitation Inspection Form will be reviewed by the Chef, who will review the findings and any corrective action plans with the General Manager / designee at the weekly 1:1 GM/Chef meeting and documented using the established meeting agenda template. The General Manager is responsible to see that the corrections are completed and monitored. Refer to C 240 POC

Survey 02BU

12 Deficiencies
Date: 12/6/2022
Type: Validation, Re-Licensure

Citations: 13

Citation #1: C0000 - Comment

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Not Corrected
3 Visit: 8/1/2023 | Not Corrected
Inspection Findings:
The findings of the re-licensure survey, conducted 12/06/22 through 12/07/22, 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 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.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 re-visit to the re-licensure survey of 12/07/22, conducted 05/12/23 through 05/17/23 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 Home and Community Based Services Regulations.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 second re-visit to the re-licensure survey of 12/07/22, conducted 08/01/23 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.

Citation #2: C0242 - Resident Services: Activities

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Corrected: 2/5/2023
Inspection Findings:
Based on observation, interview and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and create opportunities for active participation in the community at large. Findings include, but are not limited to:During the survey, the MCC was home to 12 residents. Random resident observations made on 12/06/22 and 12/07/22, review of the activity calendar, and interviews with staff revealed the following: a. The December 2022 Memory Care Activity Program calendar provided during the entrance conference indicated the following activities would occur on 12/06/22:* 9:00 am: News;* 9:30 am: Mini Mani's:* 10:00 am: Painting with Margi;* 11:30 am: Balloon Toss;* 1:00 pm: Fitness with Sam;* 2:00 pm: Baking with Staff; and * 3:30 pm: Mind Game.On 12/06/22, the only facility led activities observed in the MCC between 9:30 am - 3:30 pm was a painting activity. Although television movies and holiday music played sporadically, no other activities were observed. b. On 12/07/22, the activity calendar and a posted daily activity plan (written on a dry erase board in the activity area) noted the following activities would occur:* 9:00 am: News;* 9:30 am: Coloring;* 9:30 am: Craft time;* 10:00 am: Tea time with staff;* 10:00 am: Hydration and snacks;* 11:00 am: Daily Chronicle;* 11:00 am: Fitness with Sam;* 1:15 pm: Puzzle time;* 2:00 pm: Hot cocoa;* 3:00 pm: Holiday Movie;* 3:30 pm: Music Therapy; and * 4:15 pm: Balloon Toss. The only facility led activities observed between 8:30 am - 3:30 pm was a holiday craft where one resident participated, and an afternoon snack of cookies and drinks. The television and holiday music played sporadically; however, no other facility led activities were observed. Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Administrator) on 12/07/22 at 3:30 pm. She acknowledged the findings.
Plan of Correction:
OAR 411-054-0030 (1)(c-d) Resident Services: Activities Staff was inserviced immediately on the importance of following scheduled activties or finding alternate options based on resident interests outlined in service plans. Operations Leader reviewed company standards related to activities in Memory Care with Memory Care Manager and General Manager. Staff training was conducted with all memory care staff related to company memory care programs to provide a daily activity program of social and recreationalactivities based on individual and groupinterests, physical. Memory Care manager to conduct a daily audit to ensure scheduled activities are being conducted. General Manager is responsible to see that the corrections are completed and monitored.

Citation #3: C0252 - Resident Move-In and Eval: Res Evaluation

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Corrected: 2/5/2023
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose records were reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in 11/2022. A review of the resident's move-in evaluation failed to address the following:* Customary routines;* Spiritual, cultural preference and traditions;* Personality including how a person copes with change or challenging situations;* Complex medication regimen;* Recent losses; and* Environmental factors that impact the residents behavior, including but not limited to: noise, lighting and room temperature.The facility's failure to complete all required elements for Resident 3's move-in evaluation was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 12/07/22. They acknowledged the findings.
Plan of Correction:
OAR 411-054-0034 (1-6) Resident Move -in and Eval: Resident EvaluationResident 3 has been reassessed and service plan was updated to reflect complete and accuragte resident care needs. Prior to the residents moving in to Memory Care, the Memory Care Manager, and Health and Wellness Director will review the evaluation- and service plan to ensure it reflects all evaluation elements. Evaluations will be reviewed 30 days after the initial move in and quaterly. Evaluation training was held with the Memory Care Manager and RCC. Evaluations will be audited by the memory care manager monthly and the H&W director, RN. Weekly meeting will be held with GM and Health and Wellness team to audit processes. General Manager will be responsible for overall compliance.

Citation #4: C0260 - Service Plan: General

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Corrected: 2/5/2023
Inspection Findings:
2. Resident 1 was admitted to the MCC in 2020 with diagnoses which included dementia. Interviews with care staff and observations of Resident 1 during the survey revealed s/he was incontinent, received assistance for several ADL care needs, and did not use a call light to summon assistance. Resident 1's service plan, dated 10/19/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:* Skin rash and treatments;* UTI medication;* Forehead wound;* Activities; and* Use of eye glasses.The need to ensure the service plan was reflective of Resident 1's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 12/07/22 at 3:25 pm. She acknowledged the findings. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.Observations of the resident and interviews with staff during the survey, and review of the clinical record including the 12/06/22 service plan and Temporary Plan of Care (TSPs) from 09/01/22 through 12/06/22, revealed the service plan was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:* Skin condition;* Bathing and shower services;* Use of boots on legs;* Toileting status;* Use of air mattress;* Use of floor mat on each side of bed; and* Ted hose status.The need to ensure the service plan was reflective of Resident 2's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 12/07/22. She acknowledged the findings.
Plan of Correction:
OAR 411-054-0036 (1-5) Service Plan: GeneralResident 1 & 2 have been evaluated, current health needs, clear direction regarding the delivery of services have been updated and are now reflective of the residents care needs. Resident 1 & 2 now address the needs listed as deficient and those service needs are reflective on the service plan. Resident # 2 has clear direction on hospice care orders in the service plan including the use of the air mattress and the floor mats on each side of the bed. Bathing services updated to reflect hospice care conducting them.Resident #1 has clear direction to reflect the needs and provide direction to the staff on how to deliver the care the resident needs. Service plan development & training was conducted by the memory care manager with the team.Weekly meeting will be held with GM and Health and Wellness team to audit processes. General Manager will be responsible for overall compliance.

Citation #5: C0280 - Resident Health Services

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Not Corrected
3 Visit: 8/1/2023 | Corrected: 6/18/2023
Inspection Findings:
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition which included documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#2) who experienced a significant change of condition in weight status. Findings include, but are not limited to:Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia and edema.During the acuity interview on 12/06/22, the resident was identified to have a weight change.The resident was observed on 12/06/22 in the dining room for lunch. The resident ate the meal independently and consumed 100 %.Resident 2's weight records were reviewed during the survey and revealed the following:* 01/05/22 - 228.0 pounds;* 06/02/22 - 252.0 pounds;* 08/04/22 - 242.0 pounds; * 11/03/22 - 252.0 pounds; and* 12/01/22 - 232.4 pounds.From 01/2022 to 06/2022, Resident 2 gained 24.0 pounds or 10.52 % of his/her body weight in five months, and from 11/03/22 to 12/01/22, the resident lost 20.6 pounds or 8.51 % of his/her body weight in a month, which represented a significant change of condition.The facility RN completed an assessment on 07/24/22 and stated the "current weight 238 [pounds]" and noted "weight entered on 6/22 is likely data error entry as all other weights are consistent and range for 6 months". However, there was no documented evidence the RN evaluated the resident's weight to support the 06/2022 weight data was an error such as a re-weigh of the resident or obtained the resident's weight in 07/2022.There was no RN assessment for the significant weight loss between 11/2022 and 12/2022 at the time of survey.The need to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 12/07/22. They acknowledged the findings.
3. Resident 6 was admitted to the facility with diagnoses including dementia, HTN and was on hospice.Resident 6's weight record was reviewed during the survey and revealed the following:* 02/2023 - 148 pounds;* 03/2023 - 140 pounds;* 04/2023 - 133 pounds; and* 05/03/23 - 136 pounds.From 02/2023 to 03/2023, Resident 6 lost 8 pounds or 5.4% of his/her body weight. Between 03/2023 to 04/2023, Resident 6 lost another 7 pounds or 5% of his/her body weight, both of which represented a significant change of condition.There was no documented evidence the RN conducted an assessment of the resident's weight loss from 02/2023 through 04/2023, which included findings, a description of resident status and a plan of care to address the weight loss. Resident 6 was observed eating lunch and snacks independently on 05/15/23 and 05/16/23. S/he ate well when placed with other residents who were eating.On 05/11/23, one month after the second significant weight loss, the new facility RN, Staff 12, completed a significant change of condition assessment for the weight loss and included interventions of encourage resident to eat and drink at meal times, encourage resident to snack during the day and remind of all meals.The requirement to document a timely RN assessment of a resident's significant change of condition was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 05/17/23. They acknowledged the findings. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition, which included documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 6) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:Resident 1 was admitted to the facility with diagnoses including dementia and Kidney disease (stage III).Resident 1's record was reviewed during the survey and revealed the following:1. The MCC "Weight Report" for Resident 1 documented a monthly gain 26 pounds in 04/2023, and then a loss of 17 pounds in 05/2023.*03/2023 179 pounds;*04/2023 205 (26 pound weight gain); and*05/2023 188 (17 pound weight loss).The significant weight fluctuations between 03/2023 and 04/2023 and also 4/2023 to 5/2023 constituted a significant change of condition.In interview on 05/09/23 Staff 1 (Administrator) stated the weight fluctuation were data errors due to staff using different scales for weights, however, there was no re-weigh, evaluation of the weight data, or referral to the RN for assessment of the weight fluctuation. 2. A progress note dated 04/23/23 noted Resident 1 was found on the floor "holding left shoulder stating it hurts terrible", and "called 911 to have resident evaluated." Resident 1's service plan was updated at return from the emergency room to include the information "returned with a broken left collarbone and large skin tear on left elbow".A 04/24/23 progress note documented "resident struggles with transfers since return from the hospital. Often becomes flustered making ADL unsafe for resident and staff". Also on 04/24/23, a note stated "continue to use PRN acetaminophen (pain medicine) and Risperidone (psychotropic medication) every 6 hours for pain and agitation", and on 04/25/23 "Mobility Change: needing two person assist when getting up from dining room chairs".A "RN post-fall note" dated 04/24/23 failed to document or assess the "large skin tear", fractured bone, unsafe ADL, increased pain and PRN pain medication use, mobility changes requiring two person assist, or to update the service plan with fall interventions.The requirement to document an RN assessment of a resident's significant change of condition that included assessment, findings, resident status, and service plan interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 05/17/23. They acknowledged the findings.
Plan of Correction:
OAE 411-054-0045 (1) (a-f) (A) (C-F) Resident health servicesResident 2 has been reassessed for Significant Change of Condition for weight change by the RN. The service plan has been updated to reflect those changes. Memory care manager and RN will review notes, incident reports and alerts daily and will have the assessments and service plan updates completed for all the significant change of conditions within 48 hours. Memory Care Manager will review notes, incident reports, and alerts daily and communicate significant change of conditions to RN. All care staff were re-trained on reporting changes for residents per company policy. RN will have assessment and service plan updates completed for all significant changes of conditions within 48 hours.Service Planning and Significant Change of Condition training was conducted by H&W Director and Corporate RN with the nursing team. All care staff were re-trained on reporting changes for residents per company policy using.Weekly meeting will be held with GM and Health and Wellness team to audit processes. Memory Care Manager will be responsible for overall compliance. C280 - OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health ServicesResident 1 has been assessed by the RN for a significan change of condition for the weight change and a weight monitoring plan of only using the weight chair for weighing not only this resicent but all residents is in place. The service plan has been updated to reflect those changes. Memory care manager and RN will review notes, incident reports and alerts daily and will have the assessments and service plan updates completed for all the significant change of conditions within the 48 hours. Memory Care manager and Resident Care coordinators will review notes, incident reports, and alerts daily and communicte those change of conditions to the RN. All the staff have been re-trained on the process of reporting changes for residents per our company policy. The RN will have all significant change of conditions completed withing 48 hours. Service plan and change of condittion training completed by the H&W director as well as the RN with the nursing team. The staff of the Memory care community were trained on reporting changes for the residents per company policy. Weekly meeting is held for the H&W team, GM to discuss residents of concern and ensure compliance is being met. Memory Care Manager will be responsible for the overall compliance.

Citation #6: C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Corrected: 2/5/2023
Inspection Findings:
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 2 sampled residents (#2) who received outside services. Findings include, but are not limited to:Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia and right foot pain. During the acuity interview on 12/06/22, the resident was identified to receive hospice services.Resident 2's clinical record, dated 10/04/22 through 12/13/22, was reviewed during the survey and revealed the following outside provider recommendations:* A 12/02/22 note instructed staff to try to keep "[resident] in bed. Will talk w/[with] provider about course of ABX [antibiotic]"; and* On 12/03/22, a note indicated "if pt [resident] is bedbound, please make sure to reposition Q4H [every four hours] to maintain skin integrity".There was no documented evidence the recommendations were communicated to staff or implemented. On 12/07/22, the need to ensure on-going coordination of care was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator). Staff acknowledged the findings.
Plan of Correction:
OAR 411-054-0045 (2) Res Hlth Srvc: on-and Off- site health srvc.Resident 2 has been evaluated, service plan has been updated to reflect current needs and home health recommendations. Coordinator, Memory Care manager, and RN have been trained to request all notes from Home Health during their visits, if unable to obtain they will call the Home health agency to obtain notes. Home Health/outside provider notes will be reviewed daily by the memory care team as well as the licensed nurse during the clinical meetings and recommendations will be updated in service plan as needed. Coordination of care training has been provided by the health and wellness director. Service Plans will be audited quarterly to ensure HH recommendations are incorporated and updated in service plans. Weeky meeting with GM and Health and Wellness team take place to monitor compliance.Memory Care Manager will be reponsible for monitoring compliance.

Citation #7: C0420 - Fire and Life Safety: Safety

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Corrected: 2/5/2023
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month, and fire/life safety instruction was provided to staff on alternating months. Findings include, but are not limited to:On 12/06/22, fire drill and fire/life safety training records for the previous six months were requested.Review of the documentation provided identified the following: * No fire drills had been completed in the MCC during the six-month time frame reviewed; and * No fire and life safety instruction was provided to staff. The requirements regarding fire drills and fire/life safety instruction for staff were reviewed with Staff 1 (Administrator) on 12/06/22 at 2:00 pm. The findings were acknowledged.
Plan of Correction:
OAR 411-054-0090 (1) (a-d) Fire and LIfe Safety: Drills and instructionSOD placed in fire drill binder as the vilation cannot be corrected for past dates. Operations Director has provided fire drill process and documentation education to the plant operations supervisor. Plant operations supervisor will ensure a separate memory care drill and staff training is conducted in compliance with company policy. General manager will audit all fire drills for the memory care monthly and hold weekly meetings with Plant Operations Director to monitor ongoing compliance.

Citation #8: C0422 - Fire and Life Safety: Training For Residents

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Corrected: 2/5/2023
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and annually. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation of fire and life safety training provided to residents within 24 hours of move in; and * Documentation of annual fire and life safety training provided to residents.The need to ensure residents received fire and life safety training within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Administrator) on 12/07/22 at 1:15 pm. She acknowledged the findings. No further information was provided.
Plan of Correction:
OAR 411-054-0090 (5) Fire and LIfe Safety:Training for residentsSOD placed in fire drill binder as the vilation cannot be corrected for past dates. Operations Director has provided fire drill process and documentation education to the plant operations supervisor. Plant operations supervisor and or MC manager will ensure resident has been instructed on the procedures per OFC within 24 hours of admission into Memory Care and will be re-insturcted annually. Documentation will be keep to reflect those trainings. Weekly meeting will be held between GM and Plant Operations Supervisor to monitor compliance.General Manager will be reponsible for monitoring compliance.

Citation #9: C0455 - Inspections and Investigation: Insp Interval

Visit History:
2 Visit: 5/17/2023 | Not Corrected
3 Visit: 8/1/2023 | Corrected: 6/18/2023
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 280.
Plan of Correction:
C 455 OAR 411-054-0105 (2-4)refer to C280

Citation #10: Z0142 - Administration Compliance

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Corrected: 2/5/2023
Inspection 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 242, C 420 and C 422.
Plan of Correction:
OAR 411-057-0140 (2) Administration complianceAll staff that will be conducting, monitoring, and reviewing the preceeding tags: C242, C420, and C422 have been instructed and trained on proper protocols to ensure that resident evaluations, service plans, coordination of care, significant change of condition processes meet the licensing requirements for the facility.General Manager and Memory Care Manager will be reponsible for monitoring compliance.

Citation #11: Z0155 - Staff Training Requirements

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Corrected: 2/5/2023
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly hired staff (#6) completed all required pre-service training prior to performing any job duties, and 2 of 3 direct care staff (#s 9 and 10) failed to complete a minimum of 16 hours of annual in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours of annual in-service training on dementia care. Findings include, but are not limited to:Staff training records were reviewed with Staff 1 (Administrator) on 12/07/22. The following deficiencies were identified:1. Staff 6 (CG) was hired 09/07/22. a. There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties: * Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.)* 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.2. Staff 9 (CG) was hired 10/17/19 and Staff 10 (CG) was hired 11/08/19. Review of annual training, based on their anniversary date of hire, revealed the following:a. Staff 9 lacked documented evidence of having completed at least 16 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting, including six hours related to dementia care.b. Staff 10 lacked documented evidence of having completed at least 10 hours of annual in-service training related to the provision of care for persons in a community-based care setting.Staff training requirements were reviewed with Staff 1 (Administrator) on 12/07/22. She acknowledged the findings.
Plan of Correction:
OAR 411-057-0155 (1-6) Staff Training Requrements:Copy of Sod will be placed in employee file for Staff 6, 9, and 10 and Staff 6, 9, 10 will complete required trainings on Relias and Memory Care Manager has completed their observations for competency. Operations Leader provided training for Memory Care Manager on new hire training process and requirement. All staff that are hired will be required to complete all required relias trainings to meet the licensing rules. Staff will continue to conduct continuing education training throughout the year to meet the required 16 hours of training annually. Memory care manager as well as RCC will check on staff relias training weekly to ensure that trainings are being completed and done on time. Annual training will also be completed using Relias and Relias records will be audited quarterly by Memory Care Manager. Weekly department meeting will be conducted to monitor compliance.The General Manager is responsible to see that the corrections are completed and monitored.

Citation #12: Z0162 - Compliance With Rules Health Care

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Not Corrected
3 Visit: 8/1/2023 | Corrected: 6/18/2023
Inspection Findings:
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, C 260, C 280 and C290.

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 C 280.
Plan of Correction:
OAR 411-057-0160 (2b) Compliance with Rules Health CareMemory care manager as well as RCC & facility RN will ensure that resident routines are identified and in the service plan for the direct care staff to be able to provide the care for the resident. Proper coordination of care is added to the service plan for residents for staff to care for the residents based on their individual care needs and routines. related to C252, C260, C280, C290.Weekly meeting with General Manager and Health & wellness team will be held to monitor compliance. Memory Care Manager will be responsible for compliance. Z-162 - OAR 411-057-0160(2b)

Citation #13: Z0173 - Secure Outdoor Recreation Area

Visit History:
1 Visit: 12/7/2022 | Not Corrected
2 Visit: 5/17/2023 | Corrected: 2/5/2023
Inspection Findings:
Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to:During the survey, the following was revealed:* The doors to access interior courtyard were observed to be unlocked during daylight hours on 12/06/22 and 12/07/22;* When the doors were opened, there was no sound to alert staff; and* Staff 11 (Maintenance Director) was unsure about the alert system and the policy detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather.On 12/07/22, Staff 1 confirmed the facility did not have a written policy for when the courtyard doors would be locked. On 12/07/22 at 4:30 pm, during the exit interview, Staff 1 and Staff 3 (ALF Administrator) acknowledged the above findings.
Plan of Correction:
OAR 411-0057-0170 Secure Outdoor Recreation Area. Operations Director reviewed company Opal Key Control policy with General Manager and Memory Care Manager. Doors to courtyard are not locked, they are alarmed 24 hours a day to allow resident access to secured courtyard. When door opens alert of the alarm will be sent to all memory care staff requiring staff to check the courtyard and ensure resident safety. During bad weather staff will be instructed by Memory Care manager to lock courtyard doors to ensure resident safety. Locking mechnaism will be added to courtyard doors. Staff will be inserviced on company Key Control policy which outlines monitoring and securing of enclosed courtyard. Compliance will be reviewed in weekly meetings. Memory Care Manager will be responsible for overall compliance.

Survey QTJU

3 Deficiencies
Date: 11/29/2022
Type: State Licensure, Other

Citations: 4

Citation #1: C0000 - Comment

Visit History:
1 Visit: 11/29/2022 | Not Corrected
2 Visit: 5/4/2023 | Not Corrected
3 Visit: 7/28/2023 | Not Corrected
Inspection Findings:
The findings of the kitchen inspection, conducted 11/28/22 through 11/29/22, 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 first revisit to the kitchen inspection of 11/29/22, completed on 05/04/23, 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 11/29/22 kitchen inspection, conducted on 07/28/23, are documented in this report. It was determined the facility was in substantial compliance with 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.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
1 Visit: 11/29/2022 | Not Corrected
2 Visit: 5/4/2023 | Not Corrected
3 Visit: 7/28/2023 | Corrected: 6/18/2023
Inspection 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:Observations of the Assisted Living kitchen with Staff 4 (Cook) on 11/28/22 at 9:30 am, revealed the following:*The kitchen entrance door frame had a chip in the plaster exposing the dry wall underneath;*The dish machine area above the stainless-steel table, had a softball sized hole in the wall;*The dish machine had dried food matter and splattered debris on the sides, front, legs and top; *The wall directly behind the dish machine and sink beside the dish machine had splattered food, dust and dirt; *Dish Crates around dish station were on floor;*There were boxes on floor in walk-in refrigerator, freezer and dry storage areas;*Shelving in the walk-in refrigerator and freezer had a build-up of dirt and debris; *There was a broken stainless-steel drawer face that had dirt and debris on it; *The ice machine vent, knife holder, wall outside chef's office, door frames, door jambs and Steam and Hold machine had dirt, dust and debris on them;*Two trash cans did not have lids in the area near the stove;* The can opener holder had a build-up of food debris;* The mixer backsplash had a build-up of dried food debris;*The shelf above the stove had a build-up of dirt and debris on it; *The Vulcan stove knobs and handles had sticky matter and dried food debris on them; *Lack of test strips to check sanitizers;*The dry food storage bins had dirt and food matter on their tops and sides; and*Soiled towels were on the floor underneath the bread rack.The surveyor reviewed the above areas needing cleaning and repair with Staff 1 (General Manager) and Staff 3 (Director of Regional Operations) on 11/28/22. Staff 1 and Staff 2 acknowledged the above areas needed to be cleaned and repaired.

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. This is a repeat citation. Findings include, but are not limited to:Observations of the Assisted Living kitchen with Staff 1 (General Manager) on 05/04/23 at 3:40 pm, revealed the following:* The kitchen entrance door frame had a chip in the plaster exposing the dry wall underneath and a golf ball sized hole on the frame; * The wall directly behind the dish machine and sink beside the dish machine had splattered food, dust and dirt; * Baseboard directly behind the dish machine was cracked and broken;* Shelving in the walk-in refrigerator and freezer had a build-up of dirt and debris; * There was a broken stainless-steel drawer face that had dirt and debris on it; * The ice machine vents had accumulated dust on them;* The can opener holder had a build-up of food debris;* Lack of test strips to check sanitizers;* The dry food storage bins had dirt and food matter on their tops and sides; and* Shelving in the dry food storage had a build-up of dirt and debris. The surveyor reviewed the above areas needing cleaning and repair with Staff 1 (General Manager) on 05/04/23. Staff 1 acknowledged the above areas needed to be cleaned and repaired.
Plan of Correction:
Each cited item has been cleaned/corrected to correct the rule violation affecting all residents.Operations Leader reviewed the community's Food Handling Policy with all Food & Beverage team members. A Sanitation Inspection Form has been established for the community and will be completed by a different team member on a monthly basis. The monthly Sanitation Inspection form will be reviewed by the Chef, who will review the findings and any plans with the General Manager/designee at the weekly 1:1 GM/Chef meeting and documented using the established meeting agenda template. The General Manager is responsible to see that the corrections are completed and monitored. Operation Leader and General Manager have revied the Food Handling Policy with all members of the food and beverage team. A Sanitation inspection form has been established. Chef will finalize all inspections weekly with the help of Sous Chef and Restaurant Supervisor, to ensure all aspects of the kitchen are clean and sanitized. The General Manager and the Chef will go over the weekly sanitation in their weekly meeting using the meeting template. General Manager as well as the kitchen management team will notify the plant operations supervisor of any repairs that need to be made in a timely manner. General manager and Plant operations supervisor will address any issues involving the kitchen in their weekly meeting using the meeting template. The General manager is responsible for ensuring that those responsible are being monitored and sanitation is being completed.

Citation #3: C0455 - Inspections and Investigation: Insp Interval

Visit History:
2 Visit: 5/4/2023 | Not Corrected
3 Visit: 7/28/2023 | Corrected: 6/18/2023
Inspection Findings:
Based on observation and interview, 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 C 240.
Plan of Correction:
refer to tag C240

Citation #4: Z0142 - Administration Compliance

Visit History:
1 Visit: 11/29/2022 | Not Corrected
2 Visit: 5/4/2023 | Not Corrected
3 Visit: 7/28/2023 | Corrected: 6/18/2023
Inspection Findings:
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.

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.
Plan of Correction:
Each cited item has been cleaned/corrected to correct the rule violation affecting all residents.Operations Leader reviewed the community's Food Handling Policy with all Food & Beverage team members. A Sanitation Inspection Form has been established for the community and will be completed by a different team member on a monthly basis. The monthly Sanitation Inspection form will be reviewed by the Chef, who will review the findings and any plans with the General Manager/designee at the weekly 1:1 GM/Chef meeting and documented using the established meeting agenda template. The General Manager is responsible to see that the corrections are completed and monitored. Refer to C240