Country Meadows Village

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 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 04/30/26 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas: * Both sides of hood vents above cooking equipment – dust accumulation/greasy; * Sides of deep fat fryer – greasy drips/spills; * Wall next to deep fat fryer – greasy/dust accumulation; * Shelf below grill and flat top – food debris/grease on paper liners; * Wall behind cooking equipment – grease drips/food splatter; * Plate holder/warmer – spills/caked on debris; * Floor drain under single sink – food accumulation; * Pipes on wall above spice shelves – accumulation of dust; * Ceiling vent near dishwashing area – significant dust accumulation; and * Vent, ceiling and light above service line – accumulation of dust. Other areas of concern included: * No small diameter probe/thermometer available. * Cook not wearing hair restraint. The areas of concern were observed and discussed with Staff 1 (Chef) and discussed with Staff 2 (Associate Executive Director) and Staff 3 (Executive Director) on 04/30/26. The findings were acknowledged at 12:15 pm by Staff 1 and acknowledged by both Staff 2 and 3 at 12:40 pm.

1. Both sides of hood vents above cooking equipment –dust accumulation and grease have been cleaned. Cook vents and hoods are on an approximately every 2 week cleaning schedule. The ALF Chef is responsible for ensuring the cleaning is completed. The hood vents are professionally cleaned every quarter. The Maintenance Director is in charge of the professional cleaning schedule. ALF Chef and ALF Administrator will walk kitchen routinely (at least qaurterly) to review kitchen cleanliness and adjust cleaning schedules if necessary. 2. The sides of the deep fat fryer as well as the wall next to the deep fat fryer have been cleaned. These surfaces are wiped down during daily use and are on a monthly deep clean schedule in order to clean any hard to reach areas. The ALF Chef is responsible for maintaining the cleaning schedule and ensuring completion of the task. ALF Chef and ALF Administrator will walk kitchen routinely (at least qaurterly) to review kitchen cleanliness and adjust cleaning schedules if necessary. 3. The shelf below the grill and flat top have liners which have been switched out for new liners. The liners are switched out weekly. It is the responsibility of the ALF Chef to ensure that the liners are replaced weekly. ALF Chef and ALF Administrator will walk kitchen routinely (at least qaurterly) to review kitchen cleanliness and adjust cleaning schedules if necessary. 4. The wall behind the cooking equipment have been cleaned of grease drips and food splatter. These walls are wiped down routinely by the kitchen team, wiping all areas that are easily accessible. The wall behind the cooking equipment is on a monthly deep cleaning schedule in order to access the harder to reach areas. The ALF Chef is responsible for ensuring the wall is maintained and the monthly deep cleaning is completed. ALF Chef and ALF Administrator will walk kitchen routinely (at least qaurterly) to review kitchen cleanliness and adjust cleaning schedules if necessary. 5. The plate holder cart has been cleaned thoroughly, including the lower bars near the wheels on the cart. The ALF Chef has educated his team on this area of concern and the bottom of the cart is part of the monthly deep cleaning. The ALF Chef is responsible for ensuring the monthly deep cleaning is completed. ALF Chef and ALF Administrator will walk kitchen routinely (at least qaurterly) to review kitchen cleanliness and adjust cleaning schedules if necessary. 6. The Floor drain under the single sink has been cleaned. The floor drain routinely accumulates food debris as this is our food prep sink. The dishwasher is assigned the task of checking the drain nightly and cleaning as needed. The ALF Chef is responsible for ensuring the task is completed. ALF Chef and ALF Administrator will walk kitchen routinely (at least qaurterly) to review kitchen cleanliness and adjust cleaning schedules if necessary. 7. The pipes on the wall above the spice shelves have been cleaned of any dust accumulation. These pipes are cleaned as part of the monthly deep clean. The ALF chef is responsible for ensuring the monthly deep cleaning is completed. ALF Chef and ALF Administrator will walk kitchen routinely (at least qaurterly) to review kitchen cleanliness and adjust cleaning schedules if necessary. 8. Both ceiling vents as well as the lights have been dusted/cleaned. The ceiling vents and lights are the responsibility of the Maintenance Director. The Maintenance director has been asked to put this task on a monthly schedule. It is the responsibility of the ALF Chef to ensure the cleaning has occurred. ALF Chef and ALF Administrator will walk kitchen routinely (at least qaurterly) to review kitchen cleanliness and adjust cleaning schedules if necessary. 9. A small diameter probe thermometer has been ordered. 10. All cooks have been re-educated on the requirement of wearing a hair restraint.

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).

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation and interview, it was determined the facility failed to maintain exterior pathways in good repair. Findings include, but are not limited to: On 12/17/25 at 10:35 am, during a walk-through of the facility with Staff 1 (ED) and Staff 3 (Maintenance) the following was identified: * Multiple drop-offs of two to three inches were noted along pathways around the perimeter of the facility and outside exterior doorways. The drop-offs posed a potential fall hazard for residents.; and * Multiple uneven and/or cracked pavement seams and/or sidewalk section were noted around the facility’s perimeter exterior pathways. This uneven pavement created potential trip hazards for residents. The need to ensure pathways around the facility were in good repair with no potential tripping hazards were shown to and discussed with Staff 1 and Staff 3 on 12/17/25 at 10:35 am and discussed with Staff 2 (Associate ED) on 12/17/25 at 3:00 pm. The staff acknowledged the findings.

1. Drop-Offs - DeSantis Landscaping has been contracted with to help fill areas where there are drop-offs from the sidewalk. In some reoccuring problem areas, a more permanent fill has been explored, such as rock. The project will be completed by the Compliance date of 2/16/2025. Our Maintenance Director has educated all employees on the maintenance team about this safety concern and they have been trained to observe the grounds for these issues while out and about around the campus. All maintenance employees are aware of the importance and how to report concerns. Our Maintenance Director along with our Associate Executive Director will routinely (at least quarterly) walk the grounds, specifically looking at drop offs and setting up repair for any areas of concern. 2. Sidewalks in Disrepair - CMVs Maintenance Director has an appoxy that can be used to fill oversized cracks and deteriorated sidewalks. The apoxy cannot be used in wet conditions. Our Maintenance Director is watching the weather closely and repairing sidewalks and walkways as soon as an opportunity presents itself. Our Maintenance Director has educated all employees on the maintenance team about this safety concern and they have been trained to observe the grounds for these issues while out and about around the campus. All maintenance employees are aware of the importance and how to report concerns. Our Maintenance Director, along with our Associate Executive Director will routinely (at least quarterly) walk the grounds, specifically looking at sidewalk and pathway conditions to ensure all exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways are made of hard, smooth material, accessible, and maintained in good repair.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

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 ensure the kitchen was maintained in accordance with Oregon Food Sanitation Rules. Findings include, but are not limited to: Observations of the kitchen were made at 10:55 am on 08/26/25. The following was identified: a. A build-up of dust, grease, and/or food splashes/debris was observed on the following: * The knife rack and wall behind the pastry prep area; * The plate holder, shelves, and walls around the hot food pass; * The sides, front, and knobs of the grill and fryer; * On the counter under the soda machine; and * In the cupboard and drain under the soda machine. b. The following was in need of repair/replacement: * The temperature gauge and the small thermometer in the walk-in refrigerator; and * Several rubber spatulas were worn with pieces of rubber broken off. c. Staff 4 (Cook) did not know where the test strips for the sanitizer solution were located. The strips were located by Staff 3 (Independent Living Kitchen Manager); however, they had expired in 2022. d. There were no alcohol wipes available for staff to sanitizer small diameter thermometers used for temping food. The kitchen was toured and the above areas were discussed with Staff 1 (ED) and Staff 2 (RN) at 12:08 pm on 08/26/25. They acknowledged the findings.

1. The areas needing cleaning have been cleaned. The temperature gauges and spatulas have been replaced. Test strips are now located in a more accessible area and staff has been educated. Alcohol wipes are located in the serving area for sanitizing thermometers. 2. Staff have been inserviced and will continue regular trainings monthly. Cleaning checklists have been updated and will be followed daily. 3. Weekly cleaning checklist will be reviewed by the Chef. 4. The Chef and the Administrator will monitor through checklists and review with employees.

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 ensure the kitchen was clean in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 08/31/23, between 10:45 am and 12:45 pm, the kitchen was observed to need cleaning in the following areas: * Black matter on perimeter of floor and around appliance feet throughout kitchen; * Food debris on floor behind prep table; * Brown matter buildup and debris on handle base of convection oven; * Orange debris on metal housing and knife of commercial can opener; * Black debris on fan cage mounted to wall in walk-in refrigerator; and   * Peeling coating and rust on grate of beverage machine, creating an uncleanable surface. The above areas were shown to Staff 1 (Executive Chef) and Staff 2 (Regional Culinary Director) on 08/31/23. The findings were acknowledged.

1. The kitchen floor will be professionally deep cleaned. The table has been pulled out to clean behind. The handle of the convection oven has been cleaned. The knife and metal housing have been cleaned. The fan cage was taken down from the wall, cleaned and re-mounted, The grate on the beverage machine has been replaced. 2. Areas noted have been added to the cleaning list. 3. Areas will be noted during daily, weekly and monthly walk-throughs. 4. The Chef, Regional Culinary Director and Executive Director.

The findings of the kitchen inspection, conducted 08/31/23, 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 re-visit to the kitchen inspection of 08/31/23, conducted on 10/19/23, are documented in this report. The facility was found to be 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 interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During an onsite interview on 02/15/2023, Staff #1 (S1) stated the following, " There are residents who no longer live there who need to be archived and residents who have moved in and have not yet been added to the tool. " Resident #4-5 (R4 and R5) moved into the facility a week or two ago. " For swing shift the ABST, posted staffing plan, and schedule states there are 2 Caregivers (CG) and 1 Med Tech (MT) working. " R4 moved in on 2/3/2023 and R5 moved in on 2/9/2023. During an unannounced site visit on 02/15/2023, The Compliance Specialist (CS) observed 2CG and 1 MT on duty. A record review of the Posted Staffing Plan, Staff Schedule for February 2023, Resident #3 (R3) Service Plan, Progress Notes, the breakdown of their care on the facility's ABST, and the States internal ABST website. The States internal website shows resident #4-5 were not currently entered into the tool. On 02/15/2023, these findings were reviewed and acknowledged by S1.

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 02/15/2023.  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

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 01/17/23 at 11:05 am. a. The following areas needed repair: * The linoleum floor behind the washer and dryer equipment in Laundry Room A and Laundry Room B was torn making it an uncleanable surface; and * The wall under the wastewater outlets of both washing machines in Laundry Room A had flaking and peeling paint caused by water damage. b. The following areas needed cleaning: * The ceiling vent in the dining area directly above the window for passing food trays from the kitchen was covered with layers of dust; and * Kitchen cabinet surfaces in the Activity Room had dried debris and were sticky. The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Executive Director) and Staff 3 (Maintenance Director) at 09:40 am on 01/18/23. They acknowledged the areas needing cleaning and repair.

The Laundry Room walls were scheduled to be painted and floors replaced in February.  Flooring has been ordered. The ceiling vent and Activity Room kitchen cabinets have been cleaned. These items have been added to the custodian's cleaning checklist. Monthly Executive Director

Based on observation and interview, it was determined the facility failed to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exit the ALF. Findings include, but are not limited to: The interior of the facility was toured on 01/17/23 at 11:05 am. * The doors leading to the central courtyard lacked a system that alerted staff when a resident exited the building. The building was toured and areas needing alarms were discussed with Staff 1 (Executive Director) and Staff 3 (Maintenance Director) at 09:40 am on 01/18/23. They acknowledged the need to install exit door alarms.

This is a new interpretation for door alarms to the courtyard.  Alarms are being ordered and will be installed. Alarms will be installed on doors leading out to the courtyard. Once alarms are installed they will be monitored by maintenance during monthly routine checks. Executive Director

The findings of the re-licensure survey, conducted 01/17/23  through 01/19/23, 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 and Home and Community Based Services Regulations OARs 411 Division 004. 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 of 01/19/23, conducted 04/07/23, 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 004 for Home and Community Based Services Regulations.