Deficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Kitchen
Capacity: 70
Deficiencies: 9
Sep 3, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2022-2025 with deficiency history related to kitchen, state licensure, and re-licensure surveys.
Findings
Across multiple inspections, the facility demonstrated repeated deficiencies primarily related to food sanitation and kitchen cleanliness, staffing and training requirements, service plan accuracy, medication administration, staffing tools, fire and life safety, and building exterior maintenance. Some deficiencies were corrected over time, while others remained uncorrected as of the latest visits.
Deficiencies (9)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure food was prepared and kitchen maintained according to Food Sanitation Rules with multiple sanitation and food storage violations observed across visits. |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure all staff who prepare and serve food had active food handler's certificates. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
| C0000 - Comment: Documented findings of kitchen inspection and revisits with noted compliance improvements by last revisit. |
| C0260 - Service Plan: General: Failed to ensure service plans reflected residents' needs and provided clear direction to staff for sampled residents. |
| C0310 - Systems: Medication Administration: Failed to ensure residents' MARs were accurate and provided clear instructions for PRN medications. |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity-based staffing tool meeting regulatory requirements. |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire drills were conducted and documented according to Oregon Fire Code requirements. |
| C0510 - General Building Exterior: Failed to maintain exterior pathways in good repair and keep grounds orderly and free of litter and refuse. |
Report Facts
Inspections on page: 3
Total deficiencies: 10
Total licensing violations: 5
Total notices: 1
Licensed beds: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including kitchen sanitation and food handler certificate deficiencies |
| Staff 2 | Associate Executive Director | Acknowledged findings related to kitchen sanitation and food handler certificate deficiencies |
| Staff 3 | Dining Services Director | Acknowledged findings related to kitchen sanitation and food handler certificate deficiencies |
| Staff 4 | Server | Named in food handler certificate deficiency |
| Staff 5 | Cook | Named in food handler certificate deficiency |
| Wellness Director | L.P.N./R.N. | Responsible for service plan and medication administration plan of correction |
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