Regency Park Assisted Living

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to:

On 08/21/25, from 10:25 am to 3:33 pm, interviews with staff and observations of the facility kitchen, food storage areas, food preparation, and food service were conducted. The following was identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following:

* Walls throughout the kitchen, dry food storage, and ware wash area;
* Flooring under and around large equipment and food preparation areas;
* Flooring in the dry storage room;
* Flooring in the walk-in refrigerator and freezer;
* Large vent above food preparation area;
* Ceiling and light fixtures near the large vent above food preparation area;
* Walk-in refrigerator and freezer doors and handles;
* Walk-in refrigerator vent/fan;
* Light fixture and fire sprinkler on the ceiling in the walk-in refrigerator;
* Interior and exterior of the oven;
* Surface of the grill;
* Interior and exterior of the deep fryer;
* Interior and exterior of the microwave in the kitchen;
* Dry storage door;
* Metal storage racks located in the dry storage area;
* Exterior of the rolling canisters located in the dry storage room;
* Cabinet located in the corner, to the right of the air conditioning unit;
* Open shelving in the food preparation area and interior of cabinet below the prep sink;
* Industrial mixer;
* Air conditioning unit; and
* Fire alarm on the wall under the air conditioning unit.

b. The following areas were noted in need of repair:

* There was a hole in the ceiling, above the air conditioning unit, with missing, broken, and peeling material, that was located above food preparation and serving areas;
* The walk-in refrigerator door had large area that was rust colored;
* The ceiling in the walk-in refrigerator had water dripping from the center;
* Staff reported the ovens were not used because they would smoke and the fire alarms would sound;
* The grease trap (large black box under three-compartment sink) had a missing part and staff reported there was a leaking part where a large pan was observed under the leaking area;
* Ware wash area lacked a seal around the dish pit;
* Food warmer/cart for the MCC had a bungee cord wrapped around it and staff reported it was “broken”;
* Walk-in refrigerator door had missing hardware;
* The walk-in freezer door frame had significant ice build up;
* Multiple blue bread pans had broken, chipped, cracked, and missing material;
* Walls throughout the kitchen, ware wash area, and dry storage room had missing material, holes, scratches, and chipped material;
* The doors to the dry storage room, back exit, and entry door had chipped, cracked, peeling, and missing material;
* Tiles at the entry door to the kitchen were broken and cracked;
* Two dry food canister lids had cracks and broken areas that exposed food product;
* There was a rectangular hole in the wall under the air conditioning unit;
* A cabinet located to the corner to the right of the air conditioning unit had broken, chipped, cracked, and missing material;
* Walk-in refrigerator ceiling light fixture had multiple cracks;
* The glass window located on the bottom right corner of the dining service director’s office had a hole and glass was broken;
* The steamer was noted to leak and had a saturated towel in front of the steamer throughout the survey;
* Staff reported the grill was not used because of excess smoke when used;
* The steam table had five black plastic inserts with holes melted on the corners; and
* A metal table with the industrial can opener had several holes on the surface.

c. The temperature of prepared food was not consistently taken prior to serving.

d. The temperature of a hot dog was requested prior to being served. Staff 4 (Cook) reported the temperature to be 111 degrees Fahrenheit, which did not meet the required minimum temperature.

On 08/21/25 at 2:30 pm, Staff 1 (Executive Director) and Staff 2 (Dining Service Director) completed a walk-through of the kitchen with this surveyor and reviewed the above areas noted.

The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with Food Sanitation Rules was reviewed with Staff 1 and Staff 2 on 08/21/25 at 3:19 pm. They acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to have a designated Infection Control Specialist who completed the specialized training in infection prevention and control protocols. Findings include, but are not limited to:

On 08/21/25 at 10:36 am, documentation of the designated Infection Control Specialist and Infection Control Specialist training was requested. At 2:28 pm, Staff 1 (Executive Director) reported the designated Infection Control Specialist had not completed specialized training in infection prevention and control protocols.

The need to ensure the facility had a designated Infection Control Specialist who completed the specialized training in infection prevention and control protocols was reviewed with Staff 1 and Staff 2 (Dining Service Director) on 08/21/25 at 3:19 pm. They acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

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 09/18/24 at 10:50 am, the facility kitchen was observed to need cleaning, repairs and proper food storage in the following areas:

Equipment and areas in need of cleaning included:

* Interior of microwave – food splatters;
* Food bin lids in dry storage – heavy buildup of food debris (powdered sugar, salt, oatmeal, flour and granulated sugar);
* Hood vents, ceiling of hood and sides, wall and piping behind cooking equipment – buildup of grease and dust;
* Sides and front (including oven doors, handles and knobs) of stove/grill/flat top/deep fat fryer/steamer – food spills and grease drips;
* Pan catching grease from hood – significant buildup of dust;
* Two door refrigerator on service line – interior had spills, black matter buildup, seals on doors had food debris buildup;
* Lower shelves throughout kitchen – spills, food debris;
* Flooring underneath cooking equipment and steam table – buildup of black matter; and
* Ceiling vent, ceiling light and surrounding ceiling in food prep area – significant about of dust buildup.

Equipment in need of repair:

* The dishwashing machine was not reaching required wash and rinse temperatures per data plate. Temperature logs not reflecting required temperatures. Per Staff 2 (Executive Director) the dishwashing machine was serviced and a part was ordered in the last week. Staff 4 (Maintenance Director) called the service provider during survey and reported they will be out to inspect the dishwashing machine on 09/19/24. Staff 2 will provide an update after service provide visit. In the meantime and until dishwashing machine temperatures reach required temperatures, the kitchen will use three sinks method to ensure proper sanitation of all dishes, including pots and pans.

* Walk in freezer/refrigerator had created condensation and dripping water around freezer door onto floor of refrigerator. Freezer door and door handle had significant amount of rust buildup.

Improper food storage:

* Dry storage: Scoops were stored in bulk food bins, powdered sugar, flour and granulated sugar.

The areas of concern were observed and discussed with Staff 1 (Cook/Person In Charge) and discussed with Staff 2 (Executive Director) and Staff 3 (Memory Care Director) on 09/18/24. 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:

The findings of the re-licensure survey, conducted 10/03/23 through 10/05/23, 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 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 first revisit to the re-licensure survey of 10/05/23, conducted on 02/28/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.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 10/05/23, conducted 05/15/24, 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 Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective and provided clear direction regarding the delivery of services for 2 of 6 sampled residents (#s 2 and 5). Findings include, but are not limited to:1. Resident 5 moved into the facility in 06/2023 with diagnoses including Parkinson's disease and type II diabetes.Resident 5's service plan, updated 08/08/23, temporary service plans and progress notes dated 07/02/23 through 10/02/23 were reviewed. Interviews with care staff and Resident 5 were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:* Side rail use;* Use of an air mattress while in bed;* Catheter use for bladder elimination; and* HHRN outside provider services.The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Resident Services Director, RN) on 10/04/23. They acknowledged the findings.
2. Resident 2 moved into the facility in 04/2022 with diagnoses including chronic back pain and endometrial cancer.Resident 2's service plan, last updated 01/27/23, temporary service plans and progress notes dated 06/26/23 through 09/26/23 were reviewed. Interviews with care staff and Resident 2 were conducted and observations were made. The resident's service plan was not completed following a quarterly evaluation and did not reflect the resident's needs or provide clear direction regarding the delivery of services in the following areas:* Pain, including non-pharmacological interventions and who shall provide the services, what, when, how, and how often the services shall be provided;* Use of compression stockings;* Weekly skin checks; and* Weight monitoring, including daily weights. The need to ensure service plans were completed quarterly, were reflective of the resident's care needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Resident Services Director, RN) on 10/05/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, for 1 of 2 sampled residents (# 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 8 was admitted to the memory care in 08/2021 with diagnoses including chronic respiratory failure. Observations, interviews and review of the 01/04/24 service plan revealed Resident 8's service plan was not reflective of the resident's current needs and preferences in the following areas:* Use of oxygen; and* Personal companion.The need to ensure service plans were reflective of residents' current care needs, and preferences were implemented, and provided clear directions to staff was discussed with Staff 1 (ED) and Staff 3 (RN) on 02/28/24

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 5) who was being assisted with insulin injections and CBG readings by unlicensed facility staff. Findings include, but are not limited to: Resident 5 moved into the facility in 06/2023 with diagnoses including type II diabetes.During the acuity interview on 10/03/23, Resident 5 was identified to be administered insulin injections by non-licensed staff. 1. The resident's 09/01/23 through 10/03/23 MARs and initial delegation records were reviewed and identified the following:* Staff 6 (Med Tech), Staff 8 (Med Tech) and Staff 10 (Med Tech) documented on the MAR they administered insulin injections to the resident on multiple occasions;* There was no documentation of how frequently the unlicensed staff should be supervised and reevaluated, including a rationale for the frequency based on the competency of the unlicensed staff, for Staff 6, Staff 8, and Staff 10;* There was no documentation of how frequently the resident should be reassessed by the registered nurse regarding continued delegation of the task to the unlicensed staff, including rationale for the frequency based on the resident's needs; and* There was no documentation the Registered Nurse took responsibility for delegating the task to the unlicensed staff and ensured that supervision would occur for as long as the Registered Nurse was supervising the performance of the delegated task.2. Periodic inspection, supervision and re-evaluation delegation records were reviewed and identified the following:* There was no nursing assessment of the resident's condition to determine that the resident's condition remained stable and predictable; and* There was no documentation of observation of the competence of the unlicensed staff to determine they remained capable and willing to safely perform the delegated task of nursing care.On 10/04/23, the need to ensure all staff who administered insulin injections or performed delegated, taught tasks were appropriately delegated and supervised in accordance with OSBN Administrative Rules was reviewed with Staff 1 (ED) and Staff 3 (Resident Services Director, RN). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:During the survey, meal observations were made of staff in the dining room. Staff were observed removing dirty dishes, assisting residents with their napkins and utensils, touching residents and serving residents their meals without changing their gloves or performing hand washing.The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED) and Staff 3 (Resident Services Director, RN) on 10/05/23. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and documented all required components in accordance with the Oregon Fire Code every and to ensure fire and life safety instruction was provided to staff on alternating months. Findings include, but are not limited to:Review of fire and life safety records for 04/2023 through 09/2023 and an interview with Staff 1 (ED) and Staff 5 (Plant Operations Director) on 10/04/23 revealed the facility lacked documentation of the following:* Fire and life safety instruction to staff on alternate months; and* Fire drills conducted and recorded every other month according to the Oregon Fire Code.On 10/04/23, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drill documentation included required components according to the Oregon Fire Code was reviewed with Staff 1, Staff 3 (Resident Services Director, RN) and Staff 5. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure fire drills conducted every other month documented all required components in accordance with the Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:Review of fire and life safety records for 01/2024 through 02/2024 and an interview with Staff 1 (ED) and Staff 19 (Plant Operations Director) on 02/28/24 revealed the facility lacked documentation of the following:Fire drills conducted and recorded every other month lacked the following required elements: * Escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time needed; and* Number of occupants evacuated.On 02/28/24, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drill documentation included required components according to the Oregon Fire Code was reviewed with Staff 1. She acknowledged the findings.
Plant Operations Director was given proper documentation to use during fire drills to assure all required elements are included; Escape route used, problems encountered, comments relating to residents who resisted or failed to participate in the drills, evacuation time needed, number of occupants evacuated. Fire drills will be performed on "odd" months and fire life safety education to be reviewed with all staff during "even" months.Executive Director and Plant Operations Director to assure compliance quarterly and plan upcoming drills and education.

Based on observation, interview, and record review, 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 260, C 420, C 613, and C 645.

Based on observation and interview, it was determined the facility failed to ensure exterior surfaces were maintained in good repair. Findings include, but are not limited to:Observations of facility pathways around courtyards and seating areas on 10/03/23 at 9:45 am identified the following: * Multiple drop-offs of two to three inches were noted along pathway edges around the perimeter of outside courtyards and seating areas.The need to ensure pathways around the facility were in good repair with no potential tripping hazards was discussed with Staff 1 (ED) on 10/04/23 at 11:20 am. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:During a tour of the facility on 10/03/23 at 9:45 am, the following was observed:* Multiple doors, including Rooms 101, 103, 114, 119, 121, 122, 207, 222, 235, 253 and 257, had scuffs and scratches; and* Carpet was stained in front of Room 119 and between the dining room and adjacent seating area.The environment was toured on 10/04/23 at 11:20 am with Staff 1 (ED). She acknowledged the above areas needed to be cleaned and repaired.
Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:During a tour of the facility on 02/28/24 at 10:30 am, the following was observed:* Carpet was stained in front of Room 119 and between the dining room and adjacent seating area; and* Pervasive urine odor in hallway of unit 122. The environment was toured on 02/28/24 at 01:40 pm with Staff 19 (Plant Operations Director).The need to ensure the interior of the facility was kept clean and was free of unpleasant odors was discussed with Staff 1 (ED) on 02/28/24. She acknowledged the above areas needed to be cleaned and repaired.
Carpet in front of room 119 and between dining area and nearby seating were cleaned and no longer show visable staining. Community carpet cleaning placed on planned cleaning rotation at least quarterly and audited monthly by Executive Director and Plant Operations Director for continued cleanliness and or need for more extensive cleanring.Pervasive urine odor in hallway of unit 122 addressed with resident and resident POA to assure care plan is meeting needs to reduce/eliminate excessive urine odor. Care conference with POA scheduled to discuss need for additional care. Weekly audits in place to assure resident compliance with care. Odor elminating device in place near hallway of unit 122 to address any residual odor. Executive Director, Plant Operations Director and Wellness Director to assure compliance with weekly audits for lingering odor.

Based on observation and interview, it was determined the facility failed to ensure water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit. Findings include, but are not limited to:On 10/03/23, the surveyor measured water temperatures in six resident units. The water temperature ranged from 94.2 degrees to 104.6 degrees Fahrenheit. Staff 11 (Plant Ops Associate) was present for testing of the water temperatures.In an interview on 10/04/23 at 11:45 am, Staff 1 (ED) confirmed the facility was aware of the water temperature issue and was continuing to work with their vendor to adjust the water temperatures to be within the range of 110 and 120 degrees Fahrenheit.The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 1 on 10/04/23. She acknowledged the facility needed to implement a system for monitoring water temperatures.
Based on observation and interview, it was determined the facility failed to ensure water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit. This is a repeat citation. Findings include, but are not limited to:On 02/28/24, the surveyor measured water temperatures in five resident units. The water temperature ranged from 99.1 degrees to 125.7 degrees Fahrenheit. In an interview on 02/28/24 at 2:00 pm, Staff 1 (ED) confirmed the facility was aware of the water temperature issue and was continuing to work with their vendor to adjust the water temperatures to be within the range of 110 and 120 degrees Fahrenheit.The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 1 and Staff 19 (Plant Operations Director) on 02/28/24. They acknowledged the findings.
Recirculation pump replacement initiated on 3/12/2024. Water temperatures will be adjusted to ensure they are within the range of 110-120 degrees. All associates educated on importance of proper water temperatures and reporting concerns for potential out of temperature range to Plant Operations Director who will address and report out of compliance areas to Executive Director Monthly. Plant Operations Director will audit random resident apartments throughout the community weekly to assure temperature proper range, correct and address discrepancies with Executive Director. Plant Operations Director will ensure compliance.

The findings of the kitchen inspection, conducted 01/30/23, 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 revisit of the kitchen inspection of 09/14/23, conducted 10/04/23 through 10/05/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation, food service, and the activity kitchenette area on 01/30/23 revealed splatters, spills, drips, and debris noted on: - Stand mixer; - KitchenAid Mixer; - Can opener casing and blade; - Interior of drawers, - Exterior and behind the gas range and oven; - Interior of the ovens in the main kitchen and activity kitchenette area; - Open shelving; - Legs and underneath shelving; and - equipment throughout kitchen.* There were undated and unlabeled foods in the walk in refrigerator. * There was a leak in the walk in freezer creating a build up of ice to the top of the door.* A dietary staff person did not remove gloves and wash hands between scrapping dirty dishes and putting away clean dishes.Staff 1 (Dietary Services Director) and the surveyor toured the kitchens. Staff 1 acknowledged the kitchens were in need of cleaning and repair.