Inspection Report
Kitchen
Capacity: 57
Deficiencies: 11
Feb 6, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2024 with deficiency history and enforcement notices.
Findings
Across multiple inspections from 2021 to 2024, the facility showed recurring deficiencies related to food sanitation, administration compliance, service plans, and activity documentation. Some deficiencies were corrected over time, while others remained uncorrected as of the latest visits.
Complaint Details
The complaint investigation conducted on 07/20/2023 and 07/13/2023 documented findings related to compliance with OARs 411 Division 54 and 57 for Residential Care and Memory Care Communities.
Deficiencies (11)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner including food spills, damaged equipment, and improper food handling. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0000 - Comment: Findings documented for relicensure and kitchen inspections with no specific severity stated. |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of resident needs and provided clear caregiving instructions. |
| C0361 - Acuity-Based Staffing Tool: Failed to update staffing tool to accurately reflect resident care needs. |
| H1517 - Individual Privacy: Own Unit: Concerns identified regarding individual privacy in own unit. |
| H1518 - Individual Door Locks: Key Access: Units lacked lockable entrance doors accessible only by resident and appropriate staff. |
| H1580 - Limitations: Threats to Health and Safety: Concerns about individually based limitations for health and safety threats. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| Z0164 - Activities: Failed to document individualized activity plans reflective of residents' current preferences and needs. |
| C0010 - Licensing Complaint Investigation: Findings documented from complaint investigation. |
Report Facts
Inspections on page: 6
Total deficiencies: 16
Total surveys: 6
Licensing violations: 10
Notices: 2
Licensed beds: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings and acknowledgments of deficiencies |
| Staff 2 | Health Services Director / LPN or Food Service Director | Named in multiple findings and acknowledgments of deficiencies |
| Staff 3 | Resident Care Coordinator (RCC) | Named in findings related to service plans and activity plans |
| National Director of Culinary Services | Culinary Director | Provided training and education in plan of correction for kitchen deficiencies |
| Program Director | Program Director | Responsible for resident activity care plans in plan of correction |
Loading inspection reports...



