Willamette Manor

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 07/2025 with diagnoses including inguinal hernia, skin carcinoma, and hyperlipidemia. Resident 2’s clinical record was reviewed, including the current service plan, dated 01/08/26, and progress notes and temporary service plans, dated 12/02/25 through 03/02/26. Observations of the resident were made, and interviews with staff were conducted. The service plan was not reflective or did not provide clear instructions to staff in the following areas: * Transfers; * Nutrition and hydration; * Catheter care; and * Behaviors; The service plan lacked information regarding transfers for Resident 2. In an interview on 03/03/26 at 11:15, Staff 12 (CG) stated the resident required assistance from one person with a gait belt for transfers. On 03/04/26 at 12:50 pm, the need to ensure service plans were reflective of residents’ current care needs and provided clear direction to staff was discussed with Staff 1 (ED/LPN) and Staff 2 (RN). They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2020 with diagnoses including type 2 diabetes and osteoarthritis. Resident 1’s clinical record was reviewed, including the current service plan dated 02/16/26 and temporary service plans dated 02/14/26 through 03/01/26. Observations and staff interviews were conducted. The service plan was not reflective of the resident’s current needs and did not provide clear direction to staff in the following areas: * Foley catheter care and management, including daily catheter and perineal care and changing the nighttime drainage bag to the daytime leg bag; * Behavioral needs, including a description of the resident’s behaviors, and non-drug interventions for staff to implement in response to the behaviors; * Pain status, including the location of the resident’s pain and pharmaceutical and non-pharmaceutical interventions; and * Evacuation ability, including staff assistance with wheelchair use during emergency evacuation. Observations of the resident and staff interviews conducted from 03/02/26 through 03/04/26 identified the resident had a foley catheter and required staff assistance with wheelchair use. On 03/04/26 at 3:00 pm, the need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED/LPN) and Staff 2 (RN). They acknowledged the findings.

Resident 2's service plan, dated 01/08/2026 was not reflective or did not provide clear direction to staff in the following areas: *Transfers; *Nutrition and hydration; *Catheter care; *Behaviors; and *Fall interventions. Provider's Plan of Correction: 1. Resident 2's service plan was reviewed and updated to ensure it accurately reflects the resident's current needs and provides clear direction to staff. Updates included the following: *Clarified that the resident requires an escort using a wheelchair or walker when going to the dining room. *Transfer status clarified and documented as independent. *Dietary likes and dislikes updated, including fluid preferences to support nutrition and hydration. *Catheter care instructions added, including AM and PM peri-care and switching of the catheter from the day bag to the night bag. *Specific behaviors were added with appropriate staff interventions. *Fall prevention intervention added to ensure the restroom area remains free of rugs or other tripping hazards. 2. To prevent recurrence, all service plans will be reviewed for completeness and clarified by the Community Nurse and/or Executive Director before completing and posting to ensure they accurately reflect the resident's needs and provide clear direction. 3. Service plans will be reviewed quarterly, with any significant change of condition, or as needed to ensure accuracy and completeness. In addition, the Community Nurse and/or Executive Director will conduct periodic audits of service plans to ensure required care areas are clearly addressed. 4. Community Nurse and Executive Director Resident 1's service plan, dated 02/16/2026 was not reflective of the resident's current needs and did not provide clear direction to staff in the following areas: *Foley catheter *Behavioral needs *Pain status *Evacuation ability Provider's Plan of Correction: 1. Resident 1’s service plan was reviewed and updated to accurately reflect the resident’s current needs and provide clear direction to staff. The following updates were made: * Foley catheter care and management instructions were added, including daily catheter and perineal care and procedures for changing the nighttime drainage bag to the daytime leg bag. *Behavioral needs were added, including a description of the resident’s behaviors and appropriate non-pharmacological interventions for staff to implement. *Pain status was updated to include the location of the resident’s pain and both pharmacological and non-pharmacological interventions for staff to implement. *Evacuation ability was clarified to include staff assistance required for wheelchair use during an emergency evacuation. 2. To prevent recurrence, all service plans will be reviewed for completeness and accuracy by the Community Nurse and/or Executive Director prior to completing and posting to ensure the plans reflect the resident’s current needs and provide clear direction to staff. 3. Service plans will be reviewed quarterly, with any significant change in condition, or as needed, to ensure continued accuracy and completeness. The Community Nurse will also conduct periodic audits of service plans to ensure all required care areas are addressed. 4. Community Nurse and Executive Director.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 1 of 1 sampled resident (#1) who had orders for daily weights. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2020 with diagnoses including type 2 diabetes and osteoarthritis. Resident 1’s MARs, dated 02/01/26 through 03/02/26, and active signed physician orders dated 01/27/26 were reviewed. The following was identified: Resident 1 had a physician order for daily weights, with instructions documented, “Please do weights prior to eating. Notify RN if there is a two-pound weight gain in a day or five pounds in a week.” Review of the MARs showed the resident’s weight was documented on 02/01/26, 02/02/26, 02/04/26, 2/05/26, 02/13/26 and 02/28/26. There was no documented evidence the resident’s weight was obtained daily on the on the remaining days as ordered. During an interview on 03/04/26 at 1:20 pm, Staff 1 (ED/LPN) and Staff 2 (RN) confirmed the resident weights were not obtained daily as ordered. The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 and Staff 2 on 03/04/26 at 3:00 pm. They acknowledged the findings.

Resident 1 had a physician order for daily weights - there was no documented evidence the resident’s weight was obtained daily as ordered: Providers Plan of Correction: 1. Resident 1's order format was updated to separate weight documentation from other vital signs such as blood pressure and pulse. This change allows staff to accurately document when a resident refuses to be weighed rather than selecting “N/A.” Staff were instructed to document refusals appropriately and provide supporting chart note documentation when a resident declines weight monitoring. 2. The vital sign documentation format has been revised to ensure staff are able to accurately document resident weights and refusals. This change ensures weight monitoring documentation is clear, accurate, and reflective of the resident’s status. One-on-one training was completed with all medication technicians regarding proper documentation of resident refusals and the requirement to complete a chart note when a resident declines weight monitoring. 3. The Community Nurse and/or Executive Director will review documentation during routine record audits to ensure weights and refusals are documented appropriately and that required chart notes are completed. 4. Community Nurse and Executive Director.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications, including over-the-counter medications that were ordered by a legally recognized prescriber and administered by the facility for 2 of 3 sampled resident (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to 1. Resident 2 was admitted to the facility 07/2025 with diagnoses including inguinal hernia, skin carcinoma, and hyperlipidemia. Review of Resident 2’s MAR, dated 02/01/26 through 03/02/26, identified the following: a. The MAR included a prescription for routine acetaminophen 500 mg 2 tablets by mouth 3 times daily. There were also two different strengths of PRN acetaminophen. These were 500 mg caplets and 325 mg caplets. The acetaminophen instructions stated, “not to exceed 3000 mg in 24 hours”. Therefore, no PRN doses could be administered without exceeding 3000 mg. b. The MAR showed two dosages of loperamide 2 mg capsules. One entry instructed “Give 1 capsule orally for loose stool,” and the other “Give 2 capsules orally for loose stool.” There were no instructions for determining sequential order of use. On 03/04/26 at 12:50 pm, the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (ED/LPN) and Staff 2 (RN). They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2020 with diagnoses including type 2 diabetes and osteoarthritis. Resident 1’s MARs dated 02/01/26 through 03/02/26 were reviewed. The following was identified: Resident 1 had a physician order for hydroxyzine 10 mg, one tablet by mouth three times daily as needed for anxiety. The MAR did not include resident-specific parameters or instructions to guide staff on when to administer the PRN hydroxyzine. During an interview on 03/04/26 at 1:20 pm, Staff 1 (ED/LPN) and Staff 2 (RN) acknowledged the MAR did not include resident specific parameters or instructions for administration of the PRN hydroxyzine. On 03/04/26 at 3:00 pm, the need to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 and Staff 2. They acknowledged the findings.

Review of Resident #2’s MAR dated 02/01/2026 through 03/02/2026 identified unclear medication instructions. The MAR included routine acetaminophen 500 mg, two tablets by mouth three times daily, along with two different strengths of PRN acetaminophen (500 mg and 325 mg) with instructions not to exceed 3000 mg in 24 hours, which would prevent administration of PRN doses without exceeding the maximum dose. The MAR also listed two separate orders for loperamide 2 mg capsules without clear direction for use: Plan of Correction: 1. Resident #2’s medication orders were reviewed with the prescribing provider and pharmacy. The acetaminophen orders were clarified to ensure that the total daily dose does not exceed the prescribed maximum amount and to provide clear direction regarding routine versus PRN administration. The loperamide orders were also clarified to ensure clear instructions for staff regarding the appropriate dosage and administration for loose stool. The MAR was updated to reflect the clarified physician orders. 2. To prevent recurrence, the Community Nurse and/or Executive Director will review all new and updated medication orders and MAR entries for clarity, duplication, and potential medication dosing conflicts prior to implementation. Medication technicians were educated on the importance of identifying unclear, duplicate, or conflicting medication orders and the requirement to notify the Community Nurse, pharmacy, or prescribing provider for clarification before administering medications. 3. The Community Nurse and/or Executive Director will conduct routine MAR audits to ensure medication orders are clear, complete, and accurately transcribed, and that potential medication conflicts are identified and clarified promptly. 4. Community Nurse and Executive Director. Resident 1 had a physician order for hydroxyzine 10 mg, one tablet by mouth three times daily as needed for anxiety. The MAR did not include resident-specific parameters or instructions to guide staff on when to administer the PRN hydroxyzine: Plan of Correction: 1. The PRN hydroxyzine order was reviewed with the prescribing provider and clarified to include resident-specific parameters and clear guidance for staff regarding indications for administration. The MAR was updated to reflect these instructions to ensure safe and appropriate PRN use. 2. To prevent recurrence, the Community Nurse and/or Executive Director will review all new and updated PRN medication orders to ensure that each includes resident-specific parameters, indications, and administration guidance before being placed on the MAR. Medication technicians were trained on the importance of following PRN parameters as indicated on the MAR and verifying unclear orders with the Community Nurse or prescribing provider prior to administration. 3. The Community Nurse and/or Executive Director will perform routine audits of PRN medication documentation to ensure that orders are clear, complete, and include resident-specific administration parameters. 5. Community Nurse and Executive Director.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

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 on 12/10/24 from 10:00 am thru 2:00 pm revealed the following deficient practices. 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: * Ceiling/Wall adjacent to grill/stove; * Exterior sides of oven; * Range top; * Exterior sides of fryer; * Removable hood vents; * Top of knife holder; * Floors in-between/behind equipment; * Open stainless steel shelving; * Stainless steel spice shelves; * Reach in coolers and freezers; * Movable Utility/baking rack; * Counter top mixer; * Plastic trays storing clean dishes; * Exterior of reach in cooler; * Black reach in cooler door handles; * Interior of drawers in dining room beverage station; * Plastic drawer station holding bread; * Flooring in walk in freezer under/between metal racks; b. The following areas needed repair: * Holes around pipes in ceiling of condiment storage closet; * Holes around electrical conduit in kitchen area; * Industrial dish machine not consistently dispensing chemical sanitizer effectively/correctly. c. Multiple food items/packages/containers observed stored in reach in and walk in cooler without dates when opened/prepared. Multiple potentially hazardous food items found past seven days from preparation date. One item found multiple days past manufactures use by date. d. Multiple food items observed stored on the floor in the walk-in cooler, walk-in freezer and dry storage. The day of survey was not stock delivery day and Staff 2 (Dining Service Manager) acknowledged it should have been put away, but staff hand not had opportunity to get to it related to staffing concerns. e. Dish machine was tested for adequate chlorine concentration levels. Machine was run multiple times yielding no parts per million (PPM) of sanitizer. Facility had no consistent process in place to monitor sanitation levels of dish machine to ensure dishes were sanitized per rule. The facility had test strips for chlorine but were noted to be expired in 2017. The facility had a log to monitor dishwasher wash temperatures but not sanitizer ppm and the last log entry was in October 2024. f. A red surface sanitation bucket was tested for sanitizer levels. No active PPM registered on the available sanitizer strips. Staff 2 validated that facility was not changing buckets every 2 hours as required to ensure effective sanitation of surfaces and was instead changing after each meal. g. Kitchen staff were observed to handle ready to eat items with potentially contaminated gloves. This staff was observed to handle utensils, touch handles, and other potentially contaminated items or surfaces with their gloves and then touch ready to eat items. This staff was observed to not change gloves or wash hands when appropriate to ensure cross contamination did not occur. Staff was also observed to handle RTE lettuce with bare hands which is prohibited per rule. h. Food contact surfaces of utensils were observed stored exposed to potential contamination. Dining room was observed to have pre-set utensils on the tables with the food contact surfaces uncovered exposing them to potential contamination. i. Facility had a census capacity greater than 17 residents and did not have a 3 compartment sink as required. Staff 2 toured the kitchen with surveyor and was informed of concerns found and they acknowledged the issues. At approximately 1:30pm, staff 1 (HR/Facility representative) and surveyor reviewed identified areas in and they acknowledged the areas.

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: * Ceiling/Wall adjacent to grill/stove; * Exterior sides of oven; * Range top; * Exterior sides of fryer; * Removable hood vents; * Top of knife holder; * Floors in-between/behind equipment; * Open stainless steel shelving; * Stainless steel spice shelves; * Reach in coolers and freezers; * Movable Utility/baking rack; * Counter top mixer; * Plastic trays storing clean dishes; * Exterior of reach in cooler; * Black reach in cooler door handles; * Interior of drawers in dining room beverage station;* Plastic drawer station holding bread; and * Flooring in walk in freezer under/between metal racks. 1. All areas will be cleaned by 02/01/2025. 2. Daily and weekly cleaning checklists developed with Dining Service Manager weekly audits. 3. Dining Service Manager will audit cleaning checklists and audit areas on checklist and report to Executive Director weekly. 4. Executive Director. b. The following areas needed repair: * Holes around pipes in ceiling of condiment storage closet; * Holes around electrical conduit in kitchen area; and * Industrial dish machine not consistently dispensing chemical sanitizer effectively/correctly. 1. a. Holes around pipes and electricl conduit were repaired/filled on 12/31/2024. b. Industrial dish machine was serviced on 12/11/2024 where a leaking solenoid valve was replaced and intake screen was cleaned. 2. a. Maintenance team will survey area monthly for open holes in sheet rock on walls, flooring and ceiling. b. Working with EcoLab on replacement of dish machine and any dispensing error will be reported to the Dining Service Manager or Executive Director immediately. 3. a. Monthly review by Maintenance team. b. Dish machine will be checked twice daily to make sure it is operating correctly and errors will be immediately along with regular maintenance until machine is replaced. 4. Executive Director. c. Multiple food items/packages/containers observed stored in reach in and walk in cooler without dates when opened/prepared. Multiple potentially hazardous food items found past seven days from preparation date. One item found multiple days past manufactures use by date. 1. All items were removed/discarded by 12/10/2024. 2. Dates including opened/prepared/expiration along with proper storage of items will be reviewed daily and included on daily cleaning checklist. 3. Dining Service Manager will audit cleaning checklist and audit areas on checklist and report to Executive Director weekly. 4. Executive Director d. Multiple food items observed stored on the floor in the walk-in cooler, walk-in freezer and dry storage. The day of survey was not stock delivery day and Staff 2 (Dining Service Manager) acknowledged it should have been put away. 1. All items were picked up and stored properly by 12/10/2024. 2. Staff will verify stock and food items are off the floor and stored properly daily on daily cleaning checklist. 3. Dining Service Manager will audit cleaning checklist and audit areas on checklist and report to Executive Director weekly. 4. Executive Director e. Dish machine was tested for adequate chlorine concentration levels. Machine was run multiple times yielding no parts per million (PPM) of sanitizer. Facility had no consistent process in place to monitor sanitation levels of dish machine to ensure dishes were sanitized per rule. The facility had test strips for chlorine but were noted to be expired in 2017. The facility had a log to monitor dishwasher wash temperatures but not sanitizer ppm and the last log entry was in October 2024. 1. Policy and procedure written, sanitation levels will be checked at least two times per shift. Chlorine strips were purchased on 12/10/2024 and service was completed 12/11/2024. 2. Dish machine station will be completed by 02/01/2025 equipped with chlorine strips, temperature and chlorine results log along with error tracking and steps to be taken when an error occurs including a call to EcoLab and Dining Service Manager and/or Executive Director. 3. Chlorine checks will be completed twice a shift and monitored daily and recorded on the log. Dining Service Manager will review daily. 4. Executive Director. f. A red surface sanitation bucket was tested for sanitizer levels. No active PPM registered on the available sanitizer strips. Staff 2 validated that facility was not changing buckets every 2 hours as required to ensure effective sanitation of surfaces and was instead changing after each meal. 1. Policy and procedure written, sanitation buckets will be changed every 2 hours or when visibly soiled. Sanitation levels will be checked at least twice per shift and documented after each test. 2. Cleaning/sanitizing station will be completed by 02/01/2025 equiped with sanitizer testing strips, result log and laminated sign with time of last sanitizer change. 3. Sanitizing buckets will be changed every 2 hours or when visibly soiled and sanitizing levels will be checked at least twice a shift and monitored daily and recorded on the log. Dining Services Manager will review daily. 4. Executive Director g. Kitchen staff were observed to handle ready to eat items with potentially contaminated gloves. This staff was observed to handle utensils, touch handles, and other potentially contaminated items or surfaces with their gloves and then touch ready to eat items. This staff was observed to not change gloves or wash hands when appropriate to ensure cross contamination did not occur. Staff was also observed to handle ready to eat lettuce with bare hands which is prohibited per rule. 1. Kitchen staff were re-trained on proper glove wear and hand washing on 12/17/2024. 2. PPE station will be completed by 02/01/2025 equipped with gloves, aprons, and other necessary PPE. Quick glove areas reassessed to harbor ease. 3. Dining Service Manager and leadership team will monitor glove use daily by observing and monitoring during food service. 4. Executive Director h. Food contact surfaces of utensils were observed stored exposed to potential contamination. Dining room was observed to have pre-set utensils on the tables with the food contact surfaces uncovered exposing them to potential contamination. 1. All items have been properly stored. 2. Daily checklist developed. Staff will verify the proper storage of utensils both on dining tables and on dish rack daily. 3. Dining Service Manager will verify proper storage daily and weekly with audit. 4. Executive Director. i. Facility had a census capacity greater than 17 residents and did not have a 3 compartment sink as required. 1. New 3 compartment sink ordered awaiting shipment date. 2. 3 compartement sink will be installed. Currently using sink and tub to equal 3 compartments. 3. Dining Service Manager will review weekly until new 3 compartment sink is in place. 4. Executive Director. Concerns were identified in the following areas and the facility was provided with technical assistance: C 295: Per Oregon Administrative Rule 333-019- 1011(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 including possible food borne outbreaks and gastrointestinal outbreaks which includes having a food worker sick policy for exclusion as outlined in Oregon Food Sanitation Rules. 1. New policy and procedure written and implemented. 2. Quickguide posted throughout facility to help guide staff when they are sick. Infection prevention and food borne illness training will be completed every three months. 3. Will review any outbreaks and further training during quaility assurance quarterly meeting. 4. Executive Director.

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).

3. Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and diabetes (Type 2). Observations of the resident, interviews with staff and review of the service plan dated 03/21/23, showed it was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Fall interventions; * Home health physical therapy; and * Use of a walker. On 05/03/23 the need to ensure service plans were reflective of current needs and provided clear direction was discussed with Staff 1 (Executive Director) and Staff 2 (RN). 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 needs and status, provided clear direction to staff, and were implemented for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2015 with diagnoses including diabetes (Type 2), hypertension, and epilepsy. In an interview on 05/03/23 Staff 1 (Executive Director) stated Resident 1 was receiving Home Health services, and presented the surveyor with visit notes from Occupational Therapy sessions. In an interview on 05/02/23 Staff 6 (Life Enrichment Director) stated Resident 1 had exhibited disruptive behaviors during activities. Resident 1's service plan, dated 03/23/23 was not reflective or lacked clear direction to staff in the following areas: * Home Health services; and * Challenging behaviors/interventions. On 05/03/23 the need to ensure service plans were reflective of current needs, provided clear direction to staff and were implemented was discussed with Staff 1 and Staff 2. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 02/2023 with diagnoses including hypertension, hyperglycemia, and osteoarthritis. On 05/02/23 a C-PAP machine was observed in Resident 4's room, and the resident stated "I use that at night". Resident 4's service plan, dated 03/17/23 was not reflective or lacked directions to staff in the following area: * Use of C-PAP machine. In an interview on 05/03/23 Staff 2 (RN) acknowledged Resident 4 used the C-PAP, and that it was not included in the resident's service plan. On 05/03/23 the need to ensure service plans were reflective of current needs, provided clear direction to staff and were implemented was discussed with Staff 1 and Staff 2. They acknowledged the findings.

Resident 1's service plan, dated 03/23/23 was not reflective or lacked clear direction to staff in the following areas: * Home Health services; and * Challenging behaviors/interventions. Provider's Plan of Correction: 1. Service plan was updated to reflect behavior interventions and home health. 2. Service plan meetings will be completed weekly to review upcoming service plan reviews. A final review of the service plan will be completed by Community Nurse/Executive Director before closing and posting the service plan. 3. Quarterly by the Community Nurse/Executive Director unless there is a significant change of condition. 4. The Community Nurse and Executive Director. Resident 4's service plan, dated 03/17/23 was not reflective or lacked directions to staff in the following area: * Use of C-PAP machine. Provider's Plan of Correction: 1. C-PAP was added to the care plan with the understanding the that resident/family at this time manages all operations, including cleaning and ordering of supplies for C-PAP. 2. Service plan meetings will be completed weekly to review upcoming service plan reviews. A final review of the service plan will be completed by Community Nurse/Executive Director before closing and posting the service plan. 3. Quarterly by the Community Nurse/Executive Director unless there is a significant change of condition. 4. The Community Nurse and Executive Director. Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and diabetes (Type 2). Observations of the resident, interviews with staff and review of the service plan dated 03/21/23, showed it was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Fall interventions; * Home health physical therapy; and * Use of a walker. Provider's Plan of Correction: 1. Fall interventions, home health physical therapy, and the use of a walker have been added to the service plan. 2. Service plan meetings will be completed weekly to review upcoming service plan reviews. A final review of the service plan will be completed by Community Nurse/Executive Director before closing and posting the service plan. 3. Quarterly by the Community Nurse/Executive Director unless there is a significant change of condition. 4. The Community Nurse and Executive Director.

Based on interview and record review, it was determined the facility failed to determine and document what action was needed for a resident and ensure staff instructions were made part of the record for 2 of 3 sampled residents (#s 1 and 2) with a change of condition. Findings include, but are not limited to: Resident 1 and 2's current service plans and last 90 days of charting notes were reviewed during the survey. The following deficiencies were identified: 1. Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and Diabetes Type 2. a. An incident report dated 04/19/23 documented "found resident on the floor in room barely responsive" and documented low blood pressure of 80/50 and low blood sugar of 75. Resident 2 was admitted to the hospital, was diagnosed with adult failure to thrive, and had medication changes including an oral diabetes medication instead of insulin. Resident 2 returned to the facility on 04/23/23 and was monitored for "changes in behaviors or appetite." However, there was no evidence interventions or instructions for staff were determined and documented and made part of the resident record after the change of condition. b. The record documented multiple non-injury falls by Resident 1, with the following intervention developed: "remind to call for assistance". There was no documented evidence the intervention was evaluated for effectiveness following repeated falls. On 05/03/23 the need to ensure interventions or instructions for staff were determined, documented, and made part of the resident record was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2015. The resident's service plan, dated 03/23/23, progress notes, dated 02/01/23 through 05/01/23, temporary service plans, and incident reports were reviewed. The resident experienced multiple short-term changes without documentation of needed interventions or monitoring of existing interventions for the following areas: * Falls; and * Behaviors. a. The records documented three falls by Resident 1, with the following interventions developed: * Keep pathways clear; * Non-slip shoes; * Grab bars in bathroom; * Call for assistance when toileting; and * Limit items on walker. There was no documented evidence these interventions were evaluated for effectiveness, following repeated falls. b. Resident 1's service plan documented the resident "would have loud outbursts and shake his/her fist at you". Progress notes stated the resident had become "so disruptive at times, that [he/she] had been asked to leave the activity room". There was no documented evidence interventions had been developed for these behaviors. On 05/03/23 the need to ensure development of needed interventions, and monitoring of those interventions for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Resident 2 was admitted to the facility in 2017 with diagnoses including Parkinson's Disease and Diabetes Type 2. a. An incident report dated 04/19/23 documented "found resident on the floor in room barely responsive" and documented low blood pressure of 80/50 and low blood sugar of 75. b. The record documented multiple non-injury falls by Resident 1, with the following intervention developed: "remind to call for assistance". There was no documented evidence the intervention was evaluated for effectiveness following repeated falls. Provider's Plan of Correction: 1. Change of condition service plan completed including documentation of interventions and/or instructions for staff regarding recent change of condition and repeated falls. 2. Incident follow-up will be completed within one week, checking with staff for the effectiveness of fall prevention and/or instructions. RCM will review any further incidents and possible changes in conditions with the Community Nurse and Executive Director at weekly service plan meetings. A final review will be completed by Community Nurse/Executive Director before closing and posting of the service plan. 3. Quarterly by the Community Nurse/Executive Directoor/RCM unless there is a significant change of conditon or further falls. 4.  Community Nurse, RCM and Executive Director. Resident 1 was admitted to the facility in 12/2015.  The resident's service plan, dated 03/23/23, progress notes, dated 02/01/23 through 05/01/23, temporary service plans, and incident reports were reviewed. The resident experienced multiple short-term changes without documentation of needed interventions or monitoring of existing interventions for the following areas: * Falls; and * Behaviors. a. The records documented three falls by Resident 1, with the following interventions developed: * Keep pathways clear; * Non-slip shoes; * Grab bars in bathroom; * Call for assistance when toileting; and * Limit items on walker. There was no documented evidence these interventions were evaluated for effectiveness, following repeated falls. b. Resident 1's service plan documented the resident "would have loud outbursts and shake his/her fist at you". Progress notes stated the resident had become "so disruptive at times, that [he/she] had been asked to leave the activity room". There was no documented evidence interventions had been developed for these behaviors. Provider's Plan of Correction: 1. Service plan was updated to reflect interventions for falls, and behaviors. The service plan also includes behavioralist interventions and suggestions per their report. 2. Incident follow-up will be completed within one week, checking with staff for the effectiveness of fall prevention and/or instructions. RCM will review any further incidents and possible changes in condition with the Community Nurse and Executive Director at weekly service plan meetings. A final review will be completed by Community Nurse/Executive Director before closing and posting the service plan. 3. Quarterly by the Community Nurse/Executive Director/RCM unless there is a significant change of condition or further falls. 4. Community Nurse, RCM, and Executive Director.

3.  Resident 3 was admitted to the facility in 06/2022 with diagnoses including diabetes (Type 2) and chronic kidney disease (Stage 3). Review of Resident 3's MAR, dated 04/01/23 through 04/30/23 identified the following deficiencies: * On 04/02/23 the MAR lacked documentation of whether the medications vitamin D 50 MCG, Pantoprazole Sodium 1 tab, adult multivitamin 1 tab, metroprolol succinate ER 50 mg, Saccharomyces boulardii 250 mg, and gabapentin 100 mg were administered; and * The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen and tramadol. There were no instructions for the sequential order of administration. In interview on 05/03/23 Staff 2 (RN) stated she was aware of a computer issue on that day, the medications had been given as ordered, and should have been entered into the electronic MAR when the issue was resolved. On 05/03/23 the need to keep an accurate MAR of all medications that were ordered by a legally recognized practitioner and were administered by the facility was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications that were ordered by a legally recognized practitioner and were administered by the facility for 3 of 4 sampled residents (#s 1, 3 and 4) whose records were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2015. Review of Resident 1's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies: The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 500 mg and tramadol 50mg. There were no instructions for the sequential order of administration. On 05/03/23 the need to keep an accurate MAR of all medications that were ordered by a legally recognized practitioner and were administered by the facility was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings. 2. Resident 4 was admitted to the facility in 02/2023. Review of Resident 4's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies: The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 325 mg and tramadol 50 mg. There were no instructions for the sequential order of administration. On 05/03/23 the need to keep an accurate MAR of all medications that were ordered by a legally recognized practitioner and were administered by the facility was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Resident 1 was admitted to the facility in 12/2015. Review of Resident 1's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies: The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 500 mg and tramadol 50mg. There were no instructions for the sequential order of administration. Provider's Plan of Correction: 1. Parameters have been entered for PRN pain medications for all necessary MARs. 2. During our three-check medication order process the Community Nurse and RCM will review any PRN medication orders to make sure parameters are requested and put in place. 3. Quarterly by the Community Nurse, RCM, and/or Executive Director. 4. The Community Nurse, RCM, and Executive Director. Resident 4 was admitted to the facility in 02/2023. Review of Resident 4's MAR, dated 04/01/23 through 04/30/23, identified the following deficiencies: The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen 325 mg and tramadol 50 mg. There were no instructions for the sequential order of administration. Provider's Plan of Correction: 1.  Parameters have been entered for PRN pain medications for all necessary MARs. 2. During our three-check medication order process the Community Nurse and RCM will review any PRN medication orders to make sure parameters are requested and put in place. 3. Quarterly by the Community Nurse, RCM, and/or Executive Director. 4. The Community Nurse, RCM, and Executive Director Resident 3 was admitted to the facility in 06/2022 with diagnoses including diabetes (Type 2) and chronic kidney disease (Stage 3). Review of Resident 3's MAR, dated 04/01/23 through 04/30/23 identified the following deficiencies: * On 04/02/23 the MAR lacked documentation of whether the medications vitamin D 50 MCG, Pantoprazole Sodium 1 tab, adult multivitamin 1 tab, metoprolol succinate ER 50 mg, Saccharomyces boulardii 250 mg, and gabapentin 100 mg were administered; and * The MAR lacked accurate parameters for use of two PRN pain medications. These were acetaminophen and tramadol. There were no instructions for the sequential order of administration. In interview on 05/03/23 Staff 2 (RN) stated she was aware of a computer issue on that day, the medications had been given as ordered, and should have been entered into the electronic MAR when the issue was resolved. Provider's Plan of Correction: 1. Parameters have been entered for PRN pain medications for all necessary MARs. Daily audits (M-F) will now be completed to review accuarcy of the MAR. 2. During our three-check medication order process the Community Nurse and RCM will review any PRN medication orders to make sure parameters are requested and put in place. RCM will audit to make sure the daily MAR audits are being completed. 3. RCM Audit log will be turned in weekly to the Community Nurse. 4. The Community Nurse, RCM and Executive Director.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the residents were kept clean and in good repair. Findings include, but are not limited to: The facility grounds were toured with Staff 5 (Maintenance Director) on 05/02/23. The following items were in need of cleaning or repair: * Wood railing of outdoor deck near kitchen was warped, with cracked and peeling paint; * Dark stains were present on multiple carpet areas throughout the building. On 05/02/23 the areas needing cleaning and repair were shown to and reviewed with Staff 1 (Executive Director) and Staff 5. They acknowledged the findings.

The facility grounds were toured with Staff 5 (Maintenance Director) on 05/02/23. The following items were in need of cleaning or repair: * Wood railing of outdoor deck near kitchen was warped, with cracked and peeling paint; * Dark stains were present on multiple carpet areas throughout the building. Provider's Plan of Correction: 1. Wood railing will be replaced and painted. The carpet will be replaced in some areas and cleaned professionally in other areas per our professional carpet cleaning company's recommendations. 2. Our maintenance team will complete a yearly stain protective/re-painting to the back deck including an inspection. Professional carpet cleaning is now scheduled quarterly. 3. Quarterly with our Quality Assurance Meeting. 4. Maintenance Director and Executive Director.

The findings of the re-licensure survey, conducted 05/01/23 through 05/03/23  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 first re-visit to the re-licensure survey of 05/03/23, conducted on 08/10/23, 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 Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 1/26/23 at 11:45 am through 1:45 pm revealed the following deficiencies: 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: * Dining room beverage area; * Kitchen drains; * Interior and exterior of metal drawers; * Ceiling fire sprinklers and vents; * Interior and exterior of microwave; * Stove/grill/oven knobs, doors, interior, exterior; * Metal table and surrounding area beside grill/stove; * Hood above grill/stove with large accumulation of dirt/grease debris on removable vent covers; * Open shelving throughout kitchen; * Industrial mixer; * Large can opener housing; * Fans by prep/cooking/serving area; * Light fixtures and areas of ceiling; * Window seal; * Pipes and light/electrical outlet covers behind stove; * Interior and exterior of plastic drawers throughout kitchen; * Exterior of blender: * Exterior of trash cans with heavy build up of dirt/debris; * Reach in refrigerators and freezer handles, exterior and interiors; * Top of ice machine with thick layer of dust; * Plate warmer interior and exterior; and * Top of service area across from stove/grill. b. The following areas were found in need of repair: * Dishwasher hood vent rusted and with dust buildup; * Multiple light fixtures broken/cracked; * Industrial and counter top mixer with exposed metal and rusted areas; * Multiple metal shelves with damage and/or rust; * Wooden shelves with damage/exposed wood and not smooth/cleanable surfaces; * Cooling fans in walk in with dust buildup; * Cabinets and counter tops by and near beverage station in dining room with damage; * Open shelving and counter top of steam table with missing or damage to shelves causing an un-cleanable surface; * Vents/fire sprinklers in kitchen with dust/dirt build up; * Open style bait/snap pest trap in dry good storage and under prep/service table; * Interior refrigerator shelving with areas of pealing and exposed metal which was covered in a rust type substance; * Missing outlet cover in dry good storage; * Gaps in some of the sprinkler mounts; and * Coffee closet with multiple damaged shelves and place in floor with laminate flooring missing exposing under floor. c. Food items found in refrigerator and freezers that were not covered/sealed to prevent potential contamination. d. Multiple cutting boards found to be heavily scored and/or stained. e. Salad dressings not labeled with use by date, and multiple potentially hazardous food items past their use by dates. f. Kitchen staff storing personal food items in walk in cooler. Staff 2 (New Dietary Manager) and Staff 3 (Previous Dietary Manager) toured the kitchen with the Surveyor on 1/26/23. They acknowledged the above areas needing cleaning and repair. At approximately 1:00 pm, the Surveyor reviewed areas of concern with Staff 1 (Executive Director).  Staff 1 acknowledged the areas of concerns.

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: 1. *Dining room beverage area, the shelf will be removed and the legs will be replaced with stainless steel by 03/15/2023 *Kitchen drains will be cleaned by 03/15/2023 *Interior and exterior of metal drawers will be emptied and cleaned appropriately by 03/15/2023 *Celiling fire sprinklers and vents have been cleaned as of 02/09/2023 *Interior and exterior of microwave, the microwave was replaced on 02/08/2023 *Stove/grill/oven knobs, doors, interior and exterior will be deep by cleaned 02/28/2023 *Metal table and the surrounding area beside the grill/stove, the table has been removed and the area will be deep cleaned by 03/15/2023 *Hood above the grill/stove with a large accumulation of dirt/grease debris on removable vent covers, vent covers were deep cleaned on 01/27/2023 *Open shelving throughout the kitchen will be deep cleaned or replaced by 03/15/2023 *Industrial mixer was removed from service on 02/09/2023 *Large can opener housing was been deep cleaned on 01/27/2023 *Fans by prep/cooking/serving area have been removed along with the freestanding air conditioner on 02/10/2023 and the area will be deep cleaned by 03/15/2023 *Light fixtures and areas of the ceiling, all light fixtures have either been repaired and cleaned or replaced as of 02/10/2023, the ceiling will be deep cleaned and painted by 03/15/2023 *Window seal will be deep cleaned by 03/15/2023 *Pipes and light/electrical outlet covers behind the stove will be deep cleaned by 03/15/2023 *Interior and exterior of plastic drawers throughout the kitchen will be removed as of 03/15/2023 *Exterior of the blender has been deep cleaned as of 02/10/2023 *Exterior of trash cans with a heavy build-up of dirt/debris, cans will be replaced with metal easy clean cans by 03/15/2023 *Reach-in refrigerators and freezer handles, exterior and interior, handles have been replaced on reach-in as of 02/09/2023 and both appliances will be deep cleaned by 03/15/2023 *Top of the ice machine with a thick layer of dust, has been deep cleaned as of 02/10/2023 *Plate warmer interior and exterior will be deep cleaned by 03/15/2023 *Top of the service area across from the stove/grill will be decluttered and deep cleaned by 03/15/2023 2. Awaiting quotes for an outside contracted one-time deep cleaning of the area and a weekly cleaning checklist will be implemented with kitchen staff in coordination with housekeeping to complete the weekly deep cleaning of mentioned areas . 3. Weekly by Dietary Manager and monthly with Dietary Manager and Administrator 4. Administrator b. Areas needing repair. 1. *Appointment scheduled with an HVAC company to review the Dishwasher hood vent as of 02/10/2023 *All light fixtures have been either replaced or fixed as of 02/10/2023 *Industrial and countertop mixers have been removed from service as of 02/09/2023. *Metal shelves will all be replaced or repaired, and all wood shelves in the kitchen will be removed and replaced with stainless steel by 03/15/2023 *Cooling fans in the walk-in will be cleaned by Maintenance by 03/15/2023 *Cabinets and countertop by and near the beverage station in dining room with damage, area will be cleaned and repaired by 03/15/2023 *Open shelving and countertop of steam table with missing or damaged to shelfs causing an uncleanable surface, countertop and shelving will be repaired/replaced by 02/18/2023 *Vents/fire sprinklers in kitchen with dust and dirt build-up will be cleaned be deep cleaned by 03/15/2023 *Snap pest traps have been removed as of 01/27/2023 *Shelving in the interior refrigerator have been replaced as of 02/10/2023 *Missing outlet cover in dry goods storage was replaced on 01/27/2023 *Gaps in sprinkler mounts will be repaired by 03/15/2023 *Coffee closet with multiple damaged shelves and place in the floor with laminate floor missing, flooring, and shelving replaced or repaired as of 02/10/2023 c. Food items in refrigerators or freezers not covered/sealed to prevent potential contamination, foods items will be covered/sealed per OHA Food Sanitation Rules as reviewed on 02/14/2023 with dietary staff and containers for storage will be replaced if needed by 03/15/2023 d. Multiple cutting boards were found to be heavily scored or stained, cutting boards have been disposed of and new ones have been put in service as of 02/08/2023 e. Salad dressings not labeled with a use-by date and multiple potentially hazardous food items past their used-by dates, food items will now be labeled with used-by-day using sticker including all opened or partially used items and dates will be reviewed daily, OHA Food Sanitation Rules discussed with dietary staff on 02/14/2023 f. Kitchen staff storing personal food items in the walk-in cooler, concern was discussed in a recent staff meeting on 02/14/2023, staff understand that personal food items can't be kept in kitchen   2. Kitchen staff will notify Dietary Manager when they notice areas needing repair and Dietary Manager will notify Maintenance by completing a "Request for Maintenance" form. Items in refrigerators and freezers will be audited weekly for used-by dates and to review if food is covered/sealed by Dietary Manager. The Dietary Manager will also inspect cutting boards monthly during the walk through. 3. All areas will be inspected monthly by Dietary Manager, Maintenance, and Administrator. 4. Administrator

The findings of the kitchen inspection, conducted 1/26/23, 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 revisit to the kitchen inspection of 01/26/23, conducted 04/18/23, 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.