3
Inspections
3
Deficiencies
0
Abuse Violations
9
Licensing Violations
1
Regulatory Actions
In plain language
- The most recent inspection was on March 4, 2026 (kitchen visit) and found 1 deficiency.
- Across 3 inspections since 2024, inspectors cited 3 deficiencies in total. The state lists no correction dates for them.
- No substantiated abuse violations are on record.
- The provider also has 9 substantiated licensing violations — rule breaches that did not involve abuse.
- The state has taken 1 regulatory action against this license, such as fines or conditions on the license.
Deficiencies are rule violations noted by a state inspector. Most are minor and get corrected quickly; the sections below show exactly what was found and how the provider responded.
Provider Information
Status
Open
Type
Assisted Living Facility
County
Lane
Licensed Since
January 9, 2024
Classification
Not listed
Phone
541-937-7100
Email
exdir@estherassistedliving.com
Administrator
Tonya Hodges
Accepts Medicaid
No
Memory Care
No
Inspections
3 records3/4/2026 Kitchen · Event KIT009891 Kitchen1 deficiency ▼
Deficiencies cited (1)
C0240 Resident Services Meals, Food Sanitation Rule Severity 2 ▼
Visit 1 · 3/4/2026 · Scope: L2 Widespread
No correction date recorded
Regulation (OAR)
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).
Findings
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:
Observations of the facility kitchen and food storage area were completed on 03/04/26 from 10:15 am through 1:30 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:
* Hand washing sinks;
* Interior of reach in freezer off service line;
* Reach in freezer off service line seal;
* Industrial steamer handle;
* Behind and under oven/range/grill top;
* Sides of frier/oven/grill;
* Flat top grill grease trap;
* Flat top grill;
* Exterior of convection ovens;
* Range top grates/spiders;
* Removable catch trays under range top;
* Flooring under large equipment;
* Flooring under steam table;
* Exterior and interior of plate warmer;
* Stainless steal open shelving of steam table/service line;
* Interior of deli cooler;
* Industrial can opener and housing;
* Industrial slicer;
* Industrial mixer;
* Interior of blender base;
* Exterior of trash cans;
* Interior lid of trashcan off service line;
* Top of dishwasher;
* Ceiling vent over food preparation area;
* Threshold to entry to kitchen;
* Carpet in entry way from dining room;
* Ice dispenser; and
* Walk-in cooler fan cover and ceiling;
b. The following areas were in need of repair:
* Caulking of hand washing sinks missing, or heavily stained/discolored and in need of replacement;
* Multiple gaps identified where electrical conduit entered the wall or ceiling:
* Multiple drainage hoses were observed stored deep inside floor drains causing potential for back flow issues if drains backed up and flooded;
* Ice cream chest freezer fan observed with large dust accumulation;
* Piping under three compartment sink with active leak with water accumulation on floor;
* Heavy scale build-up found on exterior of industrial dish washer; and
* Door seal on the bottom of the door to walk in cooler broken/cracked and in need of repair.
c. Commercial mixer with food contact surface of bowl and paddle stored uncovered when not in use. Several large silver bowls used for food preparation stored open to potential contamination. Multiple containers storing cooking and food preparation utensils were stored with food contact surfaces open and exposed to potential contamination.
d. Multiple cutting boards and cutting surfaces were found heavily stained and scored.
e. Multiple opened food items stored greater than 24 hours were observed without open or prepared dates. Multiple food items were found past seven days from prepared dates and/or manufacturers’ use by dates and should have been discarded.
f. Multiple food packages were found in the walk-in freezer and in dry storage area that were open or uncovered exposing the food products to potential contamination and food quality issues.
g. Multiple canned food items were found dented and should have been removed from ready to use stock.
h. Multiple staff drink cups/containers were observed to not be of the approved style lending potential contamination of lip contact surfaces.
i. A container holding used/empty soda cans or bottles was observed stored in dry storage areas next to food and/or clean equipment. The container was not cleanable and did not have a cover to prevent or detract pests/insects.
j. A scoop was observed stored in bulk food container with the handle of the scoop touching and potentially contaminating the food product.
Staff 2 (Dining Services Director) toured areas with surveyor and acknowledged the findings.
At approximately 1:30 pm, surveyor reviewed above areas Staff 1 (ED), who acknowledged the identified areas.
Plan of Correction
A. CORRECTION OF DEFICIENT PRACTICE
The facility acknowledges the findings related to failure to maintain the kitchen in a clean, sanitary, and well-repaired condition in accordance with OAR 411-054-0030 and OAR 333-150-0000.
Immediate corrective actions taken include:
A full deep cleaning of the kitchen and all identified areas was completed, including but not limited to:
1. All cooking equipment (grills, ovens, fryers, mixers, slicers, can opener, blender base)
2. Refrigeration units (reach-in coolers/freezers, walk-in cooler/freezer, seals, fans)
3. Food contact surfaces and shelving
4. Floors, walls, ceiling vents, and hard-to-reach areas (under/behind equipment)
5. Trash receptacles and dishwashing area
6. All expired, undated, dented, or contaminated food items were discarded immediately.
7. All opened food items were properly labeled and dated per food safety guidelines.
8. All food and utensils were properly covered and stored to prevent contamination.
9. Cutting boards that were heavily scored or stained were removed and replaced.
10. staff drink containers were replaced with approved, closed-lid containers with straws and relocated to designated areas.
Improper storage practices were corrected, including:
1. Removal of scoop handles from food contact surfaces
2. Removal of unclean soda container from dry storage
3. Proper separation of food and non-food items
Maintenance repairs initiated/completed:
1. Plumbing leak under 3-compartment sink repaired
2. Walk-in cooler door seal replaced
3. Caulking at sinks repaired/replaced
4. Gaps around conduit sealed
5. Drain lines repositioned to prevent backflow risk
6. Deliming/scaling of dishwasher completed
B. SYSTEMIC CHANGES TO PREVENT REOCCURRENCE
The facility has implemented the following systemic changes:
A daily, weekly, and monthly kitchen cleaning schedule has been developed and implemented, including:
1. Detailed cleaning checklists for all equipment and surfaces
2. Assigned staff responsibilities per shift
A Food Safety and Sanitation Policy has been reinforced to include:
1. Proper labeling and dating of food (24-hour and 7-day rules)
2. Proper food storage and covering requirements
3. Handling of dented/damaged goods
4. Approved staff beverage policies
A Preventative Maintenance Program has been implemented in collaboration with Maintenance Director to ensure:
1. Routine inspections of kitchen equipment and infrastructure
2. Timely repair of leaks, seals, and structural concerns
A Kitchen Organization Standard has been implemented to ensure:
1. Separation of clean and soiled items
2. Proper utensil storage (handles protected)
3. Elimination of clutter and contamination risks
C. STAFF TRAINING
All Dining Services staff have been retrained on:
1. Oregon Food Sanitation Rules (OAR 333-150-0000)
2. Infection control and sanitation practices
3. Food labeling, storage, and dating requirements
4. Cleaning expectations and schedules
5. Training was conducted by the Dining Services Director and Executive Director.
6. All new hires will receive this training during orientation.
D. MONITORING AND QUALITY ASSURANCE
To ensure ongoing compliance:
The Dining Services Director (DSD) or designee will:
1. Conduct daily kitchen sanitation inspections
2. Verify completion of cleaning logs each shift
The Executive Director (ED) or designee will:
1. Complete weekly kitchen audits using a standardized audit tool
The Maintenance Director will:
1. Conduct monthly inspections of kitchen equipment and facility condition
The facility will implement a Quality Improvement (QI) audit:
1. Monthly review of sanitation, food storage, and maintenance compliance
2. Findings reviewed in leadership/QAPI meetings
Any deficiencies identified will result in immediate corrective action and staff re-education
5. COMPLETION DATE
All corrective actions and system changes will be completed by:
?? April 15, 2026
6. RESPONSIBLE PARTIES
Executive Director – Oversight and compliance
Dining Services Director – Daily operations and sanitation compliance
Maintenance Director – Repairs and preventative maintenance
RCC/Leadership Team – Ongoing monitoring and QI participation
Visit 2 · 5/29/2026 · Scope: L2 Widespread
No correction date recorded
Regulation (OAR)
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).
5/9/2025 Complaint Investig. · Event 1TDW Complaint Investig.2 deficiencies ▼
Deficiencies cited (2)
C0360 Staffing Requirements and Training: Staffing Severity 2 ▼
Visit 1 · 5/9/2025 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
C0363 Acuity Based Staffing Tool - Updates & Plan Severity 2 ▼
Visit 1 · 5/9/2025 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
7/22/2024 Initial Licensure · Event KNXP Initial LicensureNo deficiencies ▼
No deficiencies cited
This inspection closed without citations.
Abuse Violations
No abuse violations
The state portal lists no abuse violations for this provider.
Licensing Violations
9 records3/12/2026 Failed to provide safe environment · CALMS - 00106060 Level 3Substantiated ▼
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0025(4)
Findings
The facility allegedly failed to provide reasonable precautions against conditions that may threaten the health, safety, or welfare of residents. There was no documented evidence that the facility completed the required hourly safety checks as directed in the temporary service plans dated 02/26/26 and 02/28/26, following the resident’s fall with injury. The facility’s failure to exercise reasonable precautions against conditions that may threaten the health, safety, or welfare of residents was substantiated. The investigation determined this constitutes a violation of Oregon Administrative Rules.
3/3/2026 Failed to use an ABST · CALMS - 00106056 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0037(4), (5)(a)(B) and (C)
Findings
The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.
3/3/2026 Failed to properly plan care · CALMS - 00106057 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0034(3) and (5)
Findings
The facility allegedly failed to properly develop and implement a service plan for the Alleged Victim. The facility did not complete the required evaluations at move-in, nor did it obtain sufficient information to develop an initial service plan that met the resident’s needs. The investigation determined this constitutes a violation of Oregon Administrative Rules.
3/3/2026 Failed to provide oversight and monitoring of change of condition · CALMS - 00106058 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0040(2)(a)
Findings
The facility allegedly failed to provide required oversight and monitoring. There was no documented evidence that the facility completed the required hourly safety checks as specified in the temporary service plans dated 02/26/26 and 02/28/26 following the resident’s fall with injury. The facility failed to monitor the Alleged Victim in accordance with his or her evaluated needs and service plan. The investigation determined this constitutes a violation of Oregon Administrative Rules.
3/3/2026 Failed to follow care plan · CALMS - 00106059 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0036(2)(g)
Findings
The facility allegedly failed to follow the service plan for the Alleged Victim. There was no documented evidence that the facility completed the required hourly safety checks as outlined in the temporary service plans dated 02/26/26 and 02/28/26, following the resident’s fall with injury. The facility’s failure to ensure the implementation of required services was substantiated. The investigation determined this constitutes a violation of Oregon Administrative Rules.
10/21/2025 Failed to assure resident rights · 00433955-AP-385833 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)(a) and (b)
Findings
Alleged Victim (AV) lives at Respondent’s facility, and facility staff are responsible for AV's safety and supervision. AV reported while s/he was in the bathroom Alleged Perpetrator 2 (AP2) took money from AV's bag. AP2 admitted to taking $200.00 from AV's bag while AV was in the bathroom. AP2 is responsible for financial exploitation, which constitutes abuse. The Respondent failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.
6/24/2025 Failed to protect resident from financial exploitation · 00409627-AP-360698 Level 0Substantiated ▼
Type
Licensing Violation
Level
0 - Not substantiated or inconclusive
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)(a) and (b)
Findings
Alleged Victim (AV) lives at Respondent’s facility. AV reports two watches are missing from h/h apartment, AV is unable to give a specific timeline on when the watches went missing. The items were taken by an Unknown Alleged Perpetrator #2 (AP2) and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.
6/3/2025 Failed to protect resident from financial exploitation · 00409630-AP-360704 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)(a) and (b)
Findings
On about May 29, 2025, Witness #4 (W4) withdrew $200.00 in cash from the bank to give to Alleged Victim (AV). AV spent $37.00. AV retained the rest of the cash in AV’s wallet. AV noticed that money was missing on or about June 3, 2025. An Unknown Alleged Perpetrator #2 (AP2) is responsible for financial exploitation, which constitutes abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.
12/16/2024 Failed to update staffing plan based on ABST · CALMS - 00083150 Level 3Substantiated ▼
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0037(4), (5)(a)(B) and (C)
Findings
Based on interview and record review, conducted during a site visit on 05/09/25, the facility’s failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility’s ABST and resident roster indicated all 62 residents were included in the tool and more than half had not been updated quarterly. A review of facility ODHS tool indicated the facility should be staffing to the following: Day Shift: five and half direct care staff, Swing Shift: three direct care staff, and Night Shift: two direct care staff required. A review of the posted staffing plan and staff schedule dated 12/24/24 indicated the facility was not staffing to the tool for 1 out of the 3 shifts. The facility was not consistently staffed per the posted staffing plan and ABST tool. The facility was not rounding up on their ABST hours, leaving them short half a staff member on day shift. The facility currently had 1 resident that was a two-person transfer/Hoyer lift. The facility’s failure to have a fully implemented and updated ABST was substantiated.
Regulatory Actions
1 recordALFCD26-00116 Failed to assure resident was safe · 3/13/2026 → 5/26/2026 License Condition ▼
Type
License Condition
Effective date
3/13/2026 to 5/26/2026
Reference number
CALMS - 00104386
Rules violated (OAR)
411-054-0034(1)(b)
411-054-0034(3) and (5)
411-054-0036 (2)(g)
411-054-0037(1-7)Amended: 411-054-0025(4)
411-054-0037(4), (5)(a)(B) and (C)
411-054-0040(2)(a)
Description
Based on preliminary information, received on or about March 9, 2026, a License complaint investigation was received. ODHS concludes that Respondents acts or omissions create a situation where the residents of the facility and future residents are at risk of immediate jeopardy. Facility failure to comply with Oregon Administrative Rules constitutes a threat to the health, safety, and welfare of its residents.
Findings
Facility failed to provide a safe environment