Merrill Gardens at Sheldon Park

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).

Based on observation, record review 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 areas were reviewed on 08/11/25 from 09:30 am through 2:00 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Ceiling vent above steam table * Multiple sprinkler heads and/or smoke detectors * Floor edges, corners under major equipment * Side of grill * Side of fryer * Wall beside fryer * Commercial toaster * Interior of microwave * Area directly under grill but above oven * Knobs of oven, grill, stove * Interior of ovens * Stainless steel shelving * Shelving storing spices b. The following areas were found in need of repair: * Reach in cooler by line not holding correct cold food storage temperature * Microwave interior with sections chipped/cracked yielding non smooth surfaces * Sections of caulking on service side of steam table missing/cracked * Sections of caulking by three compartment sink missing/cracked/needing repaired c. Multiple pans and/or pots were observed with heavy carbon deposits and/or grease/baked on cooked on food debris on exterior and food contact surfaces. Multiple non stick fry pans were observed with the protective coating scratched off and in need of replacement. d. Dishwashing staff did not have hair restrained when handling clean/sanitized equipment. Service staff observed to not have hair effectively retrained and hair touching table top/plates on tables during meal service. e. Kitchen staff observed over loading dishwashing racks where multiple cooking pans were not positioned so that all areas of the pan could be touched by sanitizing agents in the wash/rinse cycles as required. Multiple dishwashing racks were observed stored on the floor when not in use. f. Kitchen staff did not wash or sanitize hands on multiple occasions after handling dirty dishes, touching their face/glasses or touching potentially contaminated ares/equipment before handling clean/sanitized dishes. g. Kitchen did not have a small diameter thermometer as required. h. Staff were touching ready to eat items with gloved hands that had been potential contaminated from other tasks. Staff was observed to leave the line and enter the walk-in cooler touching the handle of the walk in multiple times. The staff member then prepared ready to eat (RTE) items such as sandwiches, salads, burger buns and relish plates. Single use gloves are to be used when handling RTE items. i. Staff was observed to serve multiple burgers without checking the temperature prior to service to residents. Staff 2 (Executive Chef) was interviewed and confirmed they were using a “fully cooked” product that came in frozen. Staff 2 verified the facility did not check the temperature of the product before service. When asked about the preparation process it was discussed that the facility warmed the frozen product in the microwave for 2-3 minutes then fried the product for an additional 3-5 minutes. Staff 2 was not aware of the manufactures recommended reheat temperatures to ensure product would be safe for consumption. Staff 2 was not able to demonstrate the temperature that the current process would produce the burgers at to ensure was served at palatable temperatures or appropriate hot holding temperatures. j. The reach in refrigerator next to the steam line was observed at 50 degrees. Multiple potentially hazardous food items were found stored in the refrigerator. A few minutes later after all items were removed the fridge it was found at 48 degrees. Logs were reviewed and there were 14 of 28 entries where the fridge was noted at above 41 degrees. The reading for 08/10 am was noted at 54 degrees, and 40 degrees at dinner meal that day. No reading was recorded for 08/11 breakfast. Staff 2 acknowledged there had been issues with that refrigerator. They were aware of the issues the previous day and had removed the items and placed in ice baths and or discarded if needed when the temperature of the refrigerator was outside parameters. Staff 2 indicated the temperature was at acceptable levels after dinner the night before. Staff 2 acknowledged it was above acceptable cold holding temperatures at the time of survey and discarded food items in the fridge. Staff 2 acknowledged the refrigerator was not correctly holding temperatures and would contact a vendor to evaluate it. Staff 2 verified food items would not be stored in the unit until it was operating correctly. k. Multiple items were found stored in walk in cooler and reach in cooler by steam line not dated when opened or prepared. One item (Tuna salad) was dated as prepared on 08/04 and was not discarded by 08/10 (seven days) as required. Staff 2 discarded the tuna salad. l. Kitchen staff was observed to check temperature of baked chicken. Staff was not observed to sanitize the thermometer prior to checking temperature. First pan of check did not read at 165 degrees or greater and was placed back in the oven to finish cooking. Second pan of chicken temperature was checked and was found greater than 165 degrees, however kitchen staff did not sanitize the thermometer after checking the temperature of the first pan of chicken therefor potentially contaminating the second pan of chicken. At approximately 12:45, surveyor reviewed identified areas with Staff 2 who acknowledged areas needed correction. At 1:30 pm the surveyor reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Executive Director) who voiced understanding of areas needing correction.

a. 1.The dust on the ceiling vent was cleaned on 08.11.2025 at time of survey. Sprinkler heads are cleaned every 6 months, with last visit in February, and were due in August. They were cleaned on 08.15.2025 as planned. The following areas have been thoroughly cleaned to be in sanitary manner: floor edges, corners under major equipment, side of grill, side of fryer, wall beside fryer, interior of microwave, area directly under grill but above oven, all effected knobs, interior of ovens, stainless steel shelving, shelving storing spices, juice machine in memory care. The toaster was replaced. 2.,3., and 4. Daily/ Weekly/ Monthly cleaning checklists implemented to clean these areas that include staff sign off that they thoroughly cleaned these areas. Checklists will then get turned into Dining Services Director who will ensure completion and compliance. Dining Services Director will then turn in these cleaning checklists to GM who will walk through and ensure completion and compliance as well. b. 1. Reach in cooler not in use until this is repaired no later than the alleged compliance date. New microwave ordered and in use. Sections of caulking on serving side of steam table, 3 compartment sink, and behind sink in kitchenette repaired. 2. Staff training done to include reporting these concerns through work order system to ensure resolution. Dining Services Director and GM will walk through weekly to ensure these areas of repair are put in as work orders and then resolved appropriately. 3. and 4. This will be evaluated weekly by walking through by GM and Dining Services Director who will also ensure completion and monitoring. c. 1. All effected pans were discarded and replaced. 2., 3., and 4. Dining Services Director will ensure that his team will not be using pans or items in this condition. He will audit this monthly to ensure compliance. GM will evaluate, walk through, and audit monthly to ensure compliance, correction, and ongoing monitoring. d. 1. Training performed with dishwasher and service staff to restrain hair. Dishwasher and service staff now restrain hair accordingly. 2. Training was performed to correct immediately. Dining Services Manager and/or cook will ensure this is done daily. 3. and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored. e. 1. Kitchen staff re-trained to ensure that racks are not overloaded nor overlapping to ensure proper sanitization in wash/rinse cycles. Additional training included to never set racks on kitchen floor. This GM and Dining Services Director have since viewed/evaluated to ensure compliance. 2., 3., and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored. f. 1. Inservice was completed for handwashing after handling dirty items, before touching clean items. 2., 3., and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored. h. 1. This was corrected immediately and directly after it occurred in front of surveyor. All kitchen/dining team in-service to be held within compliance date to ensure no future errors by staff. 2., 3., and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored. i. 1. and 2. These cooked hamburgers will be temped moving forward each time one is served to ensure service at a palatable temperature and appropriate hot holding temperature. 3. and 4. Cooks will be responsible for temping these each time. Dining Services Director will ensure compliance from the cooks to ensure completion and ongoing monitoring. GM will evaluate and ensure ongoing compliance by auditing weekly. j. 1. and 2. Reach in cooler not in use currently and will not use until repair occurs. In-service to be done within compliance date to ensure we get temperatures within compliance and if not, then we need to stop use and contact vendor immediately for repair. Once repaired, we can then resume use. 3. and 4. This will be evaluated to ensure ongoing compliance and monitoring by the Dining Services Director weekly and then by the GM monthly. k. 1. and 2. Inservice completed to ensure staff are properly dating items upon opening or repair and then discarded appropriately. Observed and audited to ensure compliance. 3. and 4. This will be evaluated to ensure ongoing compliance and monitoring by the Dining Services Director weekly and then by the GM monthly. l. 1. and 2. Inservice completed to ensure sanitization of thermometer before and after temping foods. Observed staff to ensure compliance. 3. and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored. m. 1. and 2. Protective aprons were purchased and are in use during meal service. Inservice completed to ensure expectations. 3. and 4. This will be evaluated to ensure ongoing compliance and monitoring by the Memory Care Administrator each day she is working, Dining Services Director weekly, and then by the GM monthly.

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).

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 kitchen areas were reviewed on 07/05/23 from 10:03 am through 3:15 pm and found the following:   a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Kitchen mixer stand; * Drains throughout kitchen; * Ceiling vents throughout kitchen; * Floor edges, corners and thresholds; * Grill, oven, burners, fryer, and knobs/handles of equipment;   * Ice Machine interior; * Hoods with grease and black matter; * Interior of microwave; * Handheld can openers; * Caulking around the perimeter of dish machine and beverage counter; * Interior of juice machine nozzles; and * Oven hot mitts;   b. The following areas were found in need of repair:   * Robocoupe stand cracked, the base cracked with two inch piece missing at the base of  bowl; * Pipe under the dishwasher leaking; * 3 compartment sink drain leaking; and * Hole in wall with cord coming out.   c. During lunch service at 11:50 am, a sheet pan of baked rolls was observed to be unevenly cooked with some rolls with burnt edges and dented. Staff reported that the oven did not cook evenly.   d. During lunch service, it was observed that staff dished soup from a soup warmer located next to handwashing sink. Staff were observed placing the lid of the soup warmer on top of the sink touching potentially contaminated areas. Spray and splash from hand washing causing potential contamination of prep area. Staff also observed setting clean dishes on area next to sink that was visibly wet from hand washing.   e. Multiple kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required. f. Staff not using three compartment sink method correctly. Staff not soaking dishes in sanitizer fully submerged for 1-2 minutes as required because sink leaking. Staff were rinsing the dishes with sanitizer solution. g. Kitchen did not have a small diameter thermometer as required. h. Staff were touching ready to eat items with bare hands or gloved hands that had been potential contaminated from other tasks. i. Staff served poultry item (turkey) after reaching an final cook temperature of 163 degrees. Temperature log indicated final cook temperature needed to be 140-165. It did not direct staff which meat/protein/food items needed the 140 and which needed the 165 causing errors in final cook temperatures. j. Multiple cutting boards found with heavy scoring or staining. k. Bulk flour bin lined with non food grade black garbage bag. l. Ice machine interior plastic section where ice contacts as it drops into collection bin was covered with large amounts of black mold like substance.  The ice was discarded immediately and machine area cleaned before future use. m. Multiple items found partially covered and open to potential contamination during storage.   During the kitchen tour, surveyors reviewed above areas with Staff 2 (Executive Chef) and s/he acknowledged the identified areas.  At 2:00 pm the surveyors reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Business office Manager) and Staff 1 (Administrator via phone). They acknowledged the areas.

1. *Robocoupe parts ordered to fix stand and mixer deep  cleaned.   *Pipe under the dishwasher fixed. *Leaking pipe repaired under 3 compartment sink. *Cooks have been trained to turn items in the oven half way through cooking. The oven has also been tested to make sure it's baking properly. *Soup too close to handwashing sink - splash guard divider ordered. Will be installed on 7/28/23. *Staff have been re-trained on wearing gloves, restraining hair and/or facial hair while preparing food. *Dishwasher/staff have been retrained on soaking method for 3 compartment sink. *Small diameter thermometer's have been ordered. *Staff have been retrained on glove use for all areas *Cooks have been retrained on specific tempatures for different meats. *All cutting boards have been replaced with a spare set on hand. *Flour bin has been lined with proper liner. *Ice machine was deep cleaned on 7/5/23 and is now on a monthly cleaning schedule. *Microwave will be cleaned at the end of each shift. *All staff have been retrained on covering food properly before being put away. *Caulking has been redone around the dish machine. *Interior of juice machine/nozzles have been thoroughly cleaned. *Oven mitts have been replaced and extras purchased. *Table can opener *Every item listed has been deep cleaned. 2. *Training has been completed for all the kitchen staff on cleaning daily, and deep cleaning weekly. All staff members will be held accountable so this does not happen in the future. 3.  *Weekly walk throughs will be done of every area and item listed. 4.  *GM and MD will make sure all items have been   completed.  *Executive Chef and Sous Chef will be monitoring the cleaning daily.

The findings of the kitchen inspection, conducted 7/5/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen re-licensure survey of 07/05/23, conducted 09/13/23, 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.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/16/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the unannounced complaint investigation conducted 08/16/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the unannounced complaint investigation conducted 08/16/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled residents (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 4 moved into the facility in March 2022. The resident's move-in evaluation was reviewed, and the following required elements were not addressed: * Personality: including how the person copes with change or challenging situations; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature. The need to ensure new move-in evaluations address all required elements was discussed with Staff 1 (ED) and Staff 3 (Health Services Director) on 04/12/22. They acknowledged the findings.

1.  Resident 4 will be evaluated for these two missing components. 2.  Our community uses an evaluation tool (form) in which these two components were added so that the person performing the evaluation with a potential resident will answer or complete these two components. 3. and 4.  The area needing correction will be evaluated by the Health Services Director after each new move in evaluation to all components are completed.  The Administrator will evaluate quarterly to ensure this new system is successful and corrections are completed.

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months from fire drills. Findings include, but are not limited to: On 4/12/22, the facilities Fire and life safety records were reviewed.  The records revealed fire and life safety instructions were not provided to staff on alternating months from the fire drills. In an interview on 04/12/22, Staff 1 (ED) acknowledged the facility failed to provide life safety instructions to staff on alternate months from fire drills.

1.  Life safety instructions were provided to staff on an alternating month from fire drills beginning in March 2022.   2.  Our Maintenance Director will continue to perform this life safety instructions to staff during the all staff meeting on alternating months from fire drills.   3.  and 4.  This area will be evaluated quarterly by the Administrator to ensure corrections are completed and there is ongoing compliance.

The findings of the Change of Ownership Survey, conducted 04/11/22 through 04/13/22, 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, and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the re-visit to the re-licensure survey on 04/06/22, conducted 06/15/22 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 Home and Community Based Services Regulations OARs 411 Division 004.