Footsteps at Sunnyside.

“Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local Department office, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse or neglect, for 1 of 1 sampled resident (# 2) who had injuries of unknown cause. Findings include but are not limited to: Resident 2 was admitted to the facility in 10/2020 with diagnoses including dementia. Review of the resident's clinical record, including progress notes from 12/07/25 through 03/09/26, identified the following: * On or about 02/24/25 the resident experienced bruising to the right lower extremity; and * On or about 03/07/26 the resident experienced a skin tear to the left shin. The bruise and skin tear represented injuries of unknown cause which were required to be reported to the local Department office, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. During an interview on 03/19/26 at 10:55 am, Staff 3 (LPN) reported there were no documented investigations completed for the above incidents. There was no documented evidence the facility immediately investigated the resident’s skin injuries to rule out suspected abuse or neglect, and there was no documented evidence the facility reported the incidents to the to the local Department office. The need to ensure all incidents and injuries of unknown cause were immediately investigated to rule out suspected abuse, or reported to the Department office if abuse could not be ruled out, was discussed with Staff 1 (Memory Care Administrator) and Staff 4 (ED) on 03/19/26 at 11:10 am. They acknowledged the findings. Survey requested the facility report the above incidents to the local Department office. Confirmation that the incidents were reported was received on 03/19/26 at 12:37 pm. 1.The identified incidents involving resident #2 were immediately reviewed. An investigation was completed to assess the injuries of unknown origin. The incidents were reported to the local Department office as required. 2. The Med Tech documented skin issues in the progress notes but did not fill out an incident report. That is where the process broke down. The incident report triggers the investigation to either rule out abuse or report to APS, as well as, putting out a TSP and the Skin Log. Training provided to Med Techs on when to fill out incident reports. Moreover, with the transition to Point Click Care progress notes flow to the 24 hour report for the management team to review daily. 3. Daily review of the 24 hour report, to identify progress notes that do not have a needed corresponding incident report. 4. ED, MC, and Nurse will be responsible for ensuring compliance with reporting and investigation requirements.”

“Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231. Refer to C231.”

“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 02/26/25 at 10:40 am, the facility kitchen was observed to need cleaning and repair in the following areas: * Lower shelves of prep and service counters – debris/spills/drips; * Shelf holding spice containers – debris build up; * Flooring throughout kitchen, specifically under cooking equipment, storage racks, refrigeration units – build up of black matter; * Doors and sides of steamer – drips/spills; * Area below pizza oven – drips/spills; * Wall behind dishwasher and below sink area – build up of black/brown matter; * Caulking on back splash behind sink in dishwashing area – build up of black matter; * Walls surrounding handwashing sink in dishwasher area – black/brown matter; * Side and front of deep fat fryer – drips of grease; * Table top and shelf below grill – drips/spills; * Wall behind cooking equipment – greasy/dusty * Front of oven doors – drips/spills; * Shelf above flat top grill and stove – grease/debris; * Plate warmer/holder – build up of food crumbs/debris; * Container of bowls/serving dishes next to counter holding toaster – build up of food crumbs/debris; and * Commercial stand mixer bowl guard – significant build up of food debris. Other area of concern: * Colored cutting boards – finish worn off, potentially uncleanable. The areas of concern were observed and discussed with Staff 1 (Executive Chef) on 02/26/25. 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:”

“Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“The findings of the relicensure survey, conducted 06/11/24 through 06/13/24, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. 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 relicensure survey, conducted 06/11/24 through 06/13/24, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. 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 06/13/24, conducted 11/05/24 through 11/06/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. The findings of the first re-visit to the re-licensure survey of 06/13/24, conducted 11/05/24 through 11/06/24, 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, OARs 411 Division 57 for Memory Care Communities 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 injuries of unknown cause were reported to the local SPD office or the local AAA as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse, and promptly investigate reports of abuse and suspected abuse related to falls, verbal altercations and injuries of unknown cause, for 3 of 3 sampled residents (#s 1, 2 and 3) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the memory care facility in 11/2022 with diagnoses including dementia. The resident's service plan, dated 05/07/24, incident reports, progress notes from 03/05/24 through 06/11/24, observations of the resident, and interviews with care staff revealed the following: * 04/09/24: "Alert for skin tear to L [left] hand. Hospice bath aide reported two small dime size skin tears. This [MT] cleansed wound and applied steri strips." There was no evidence the injury of unknown cause had been investigated by the facility or reported to the local SPD office as required. In an interview with Staff 1 (Reflections Administrator) on 06/13/24 at 2:12 pm, she reviewed the resident's record and stated the incident had not been investigated by the facility, or reported. The need to ensure all injuries of unknown cause were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse was discussed with Staff 1 on 06/13/24. The findings were  acknowledged and incidents reported. Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local SPD office or the local AAA as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse, and promptly investigate reports of abuse and suspected abuse related to falls, verbal altercations and injuries of unknown cause, for 3 of 3 sampled residents (#s 1, 2 and 3) whose incidents were reviewed. Findings include, but are not limited to:”

“Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 06/2020 with diagnoses of Alzheimer's disease, hypertension, and osteoporosis. Review of Resident 3's service plan, dated 05/22/24,  interviews with staff, and observations of the resident revealed the service plan was not reflective or did not provide clear direction to staff in the following areas: * Fall interventions; * Skin care/monitoring; * Nutrition and hydration; and * Individual and group activities. On 06/13/24 the need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Reflections Administrator). She acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to evaluate, determine and document what actions or interventions were needed, communicate the interventions to staff, and monitor progress of the conditions to resolution for 3 of 3 sampled residents (#'s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 12/2022 with diagnoses including dementia. The resident's clinical record, including progress notes, dated 03/11/24 through 06/11/24, short term observation notes (STO's), and the current service plan dated 03/05/24 were reviewed, and interviews were conducted. There was no documented evidence the facility evaluated, determined what resident-specific actions or interventions were needed, and communicated the determined actions or interventions to staff,  and/or documented weekly progress through resolution for the following short-term change of condition: 05/05/24 - Agitated with another resident and was making threatening/concerning comments to the point the other resident was scared. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Reflections Administrator), Staff 3 (Wellness Nurse) and Staff 4 (Wellness Director) on 06/12/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to evaluate, determine and document what actions or interventions were needed, communicate the interventions to staff, and monitor progress of the conditions to resolution for 3 of 3 sampled residents (#'s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure PRN medication used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 3 of 3 sampled residents (#s 1, 2, and 3) who were prescribed PRN psychotropic medications. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 06/2020 with diagnoses of Alzheimer's disease, hypertension, and osteoporosis. Review of Resident 3's MAR, dated 05/01/24 through 06/11/24 revealed the following: The resident was prescribed the following two PRN psychotropic medications: * Diazepam 2 mg - Take one tablet by mouth as needed for anxiety; * Lorazepam 2 mg/mL - Take .25 mL by mouth every four hours for nausea and/or agitation and/or anxiety. The MAR lacked instructions for staff regarding the sequential order of use for these PRN medications, and lacked documentation of non-pharmacological interventions to attempt prior to PRN administration. In an interview on 06/12/24, Staff 20 (MT) showed the surveyor the MAR on the computer used for medication pass. There was no documentation of the PRN parameters or non-drug interventions in Resident 3's electronic MAR. Staff 20 stated these are not seen or used in the facility's current medication system. On 06/13/24, the need to include resident-specific parameters for use of PRN psychotropic medications on the MAR, and to document non-pharmacological interventions to be attempted prior to administration was discussed with Staff 1 (Reflections Administrator). She acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure PRN medication used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 3 of 3 sampled residents (#s 1, 2, and 3) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility records on 06/12/24 identified the following deficiencies: There was no documented evidence that annual training on fire safety was provided to residents. On 06/13/24, the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Reflections Administrator) and Staff 6 (Maintenance Director). They acknowledged the findings. Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility records on 06/12/24 identified the following deficiencies: There was no documented evidence that annual training on fire safety was provided to residents. On 06/13/24, the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Reflections Administrator) and Staff 6 (Maintenance Director). They acknowledged the findings. OAR-411-054-0090 (5) Fire and life safety training for residents 1. Immediate action taken to correct the rule violation: * All residents who can comprehend have been talked to and have signed the annual fire life and safety training.Resident that can't comprehend have been notated on there indiviual form. All forms are in a binder in the maintenance office. 2. The annual training has been added to the shared calendar with ED and Maintenance for every year in June so that all that received the annual this june will on time every upcoming year and every new resdeint will also receive this training every June. 3 This will be monitored yearly in june. 4. The ED will be responsible to verify that all current residents have receieved their updated trainings and then to also verify that every june this training has been completed with every resident. OAR-411-054-0090 (5) Fire and life safety training for residents”

“Based on observation and interview, it was determined the facility failed to ensure handrails were installed at one or both sides of resident-use corridors. Findings include, but are not limited to: During the tour of the MCC building's interior, conducted on 06/11/24, it was observed a section of resident-use corridor lacked a handrail on either side to assist residents with safety. The need to ensure handrails were accessible to residents along corridors was discussed with Staff 1 (Reflections Administrator) on 07/02/24. She acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure handrails were installed at one or both sides of resident-use corridors. Findings include, but are not limited to: During the tour of the MCC building's interior, conducted on 06/11/24, it was observed a section of resident-use corridor lacked a handrail on either side to assist residents with safety. The need to ensure handrails were accessible to residents along corridors was discussed with Staff 1 (Reflections Administrator) on 07/02/24. She acknowledged the findings. OAR 411-054-0200(4) (A-b) General building interior 1. Action taken: We had a carpenter come in to take measurements for creating new hand rails on 7/16/24. 2. System is being corrected by having new hand rails made and installed by deadline. 3. The corrections will be evaluated weekly to ensure handrails are functioning properly 4. Admin and Maintenance director will be responsible to see that corrections are completed and monitored. OAR 411-054-0200(4) (A-b) General building interior”

“Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to: The facility's interior was toured on 06/11/24 at 9:54 am. The following issues were identified: * Gouges on the walls in multiple areas including the dining room, ceiling columns, and wall beneath the windows by the Administrator's office; * Window sill in the dining room; * Baseboards in the dining room were pulling away from the wall; * Baseboards and door frame around the Administrator's office; * Wall vent beneath the handrail and across from Room 109 had dust buildup; * Multiple gouges in resident apartment doors including but not limited to Rooms 113,116, 120,122, 129, 133 and the housekeeping door; * Multiple handrails throughout the facility had chipped paint and/or exposed wood; * The residential style washing machine in the small laundry room located on the unit had black matter buildup and a strong odor in the air; * Ceiling vent in the small laundry room located on the unit had a buildup of dust; and * The commercial dryer in the central laundry area was inoperable. The need to ensure the facility was clean and in good repair was discussed and the environment was toured with Staff 1 (Reflections Administrator) and Staff 6 (Maintenance Director) on 06/13/24. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to: The facility's interior was toured on 06/11/24 at 9:54 am. The following issues were identified: * Gouges on the walls in multiple areas including the dining room, ceiling columns, and wall beneath the windows by the Administrator's office; * Window sill in the dining room; * Baseboards in the dining room were pulling away from the wall; * Baseboards and door frame around the Administrator's office; * Wall vent beneath the handrail and across from Room 109 had dust buildup; * Multiple gouges in resident apartment doors including but not limited to Rooms 113,116, 120,122, 129, 133 and the housekeeping door; * Multiple handrails throughout the facility had chipped paint and/or exposed wood; * The residential style washing machine in the small laundry room located on the unit had black matter buildup and a strong odor in the air; * Ceiling vent in the small laundry room located on the unit had a buildup of dust; and * The commercial dryer in the central laundry area was inoperable. The need to ensure the facility was clean and in good repair was discussed and the environment was toured with Staff 1 (Reflections Administrator) and Staff 6 (Maintenance Director) on 06/13/24. They acknowledged the findings. OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors 1. a.Gouges on the walls in multiple areas including dining room, ceiling columns, and wall beneath the window by administrators office, windown sill in the dining room will  be sanded, textured, and painted. b. Baseboards in dining room has been nailed into place and will be painted. c. Wall vents beneath the handrail and across from room 109 has been cleaned the day of survey. d. Gouges in multiple residents apartment doors will be sanded and painted. e. Chipped paint and/or exposed wood on the handrails will be sanded and painted. f. ceiling vent in small laundry room with build up dust has been cleaned the day of survey. g. dryer that was inoperable will be replaced with new dryer. 2. i. Maintenece Director, Admin, Ed and other team members will be monitoring daily with walk throughs. 3. Daily 4. Maintence Director, Admin,and Ed will be responsible to see that the corrections are completed/monitored. OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors”

“Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 231, C 422, and C 513. Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 231, C 422, and C 513. OAR 411-057-0140(2) Administration Compliance Refer to C 231, C 422 and C 513 OAR 411-057-0140(2) Administration Compliance Refer to C 231, C 422 and C 513”

“Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C 270, C 280, and C 330. Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C 270, C 280, and C 330. OAR 411-057-0160(2b) Compliance with Rules Health Care Refer to C 260, C 270, C 280 and C 330. OAR 411-057-0160(2b) Compliance with Rules Health Care Refer to C 260, C 270, C 280 and C 330.”

“Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2 and 3's current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Reflections Administrator) on 06/13/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2 and 3's current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Reflections Administrator) on 06/13/24. They acknowledged the findings. OAR 411- 057- 0160(2)(c)(A)(B) Nutritional and Hydration Refer to C 260 OAR 411- 057- 0160(2)(c)(A)(B) Nutritional and Hydration Refer to C 260”

“Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. see above see above There are no detail notes for this visit.”

“The findings of the kitchen inspection, conducted 12/13/23, 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 kitchen inspection, conducted 12/13/23, 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 12/13/23, conducted 02/22/24, 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. The findings of the revisit to the kitchen inspection of 12/13/23, conducted 02/22/24, 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 clean in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 12/13/23 at 11:00 am, the facility was observed to need cleaning in the following areas: * The bottom shelf of the freezer on the service line - food debris accumulation; * The hood vents above the grill/stove had grease/dust accumulation; * The vent above the dishwasher had an accumulation of dust; * The wall behind the dishwasher and the spray hose sink had dust and brown matter accumulations; * The interior of the microwave (next to the juice machine) had food splatters; and * The food bin lids under the prep area had a significant accumulation of food debris. The areas in need of cleaning were observed and discussed with Staff 1 (Executive Chef) and discussed with Staff 2 (Wellness Director) on 12/13/23. The findings were acknowledged. Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 12/13/23 at 11:00 am, the facility was observed to need cleaning in the following areas: * The bottom shelf of the freezer on the service line - food debris accumulation; * The hood vents above the grill/stove had grease/dust accumulation; * The vent above the dishwasher had an accumulation of dust; * The wall behind the dishwasher and the spray hose sink had dust and brown matter accumulations; * The interior of the microwave (next to the juice machine) had food splatters; and * The food bin lids under the prep area had a significant accumulation of food debris. The areas in need of cleaning were observed and discussed with Staff 1 (Executive Chef) and discussed with Staff 2 (Wellness Director) on 12/13/23. The findings were acknowledged. OAR 333-150-0000 -Cleanliness and Sanitation 1. Actions taken to correct rule violation include: a) All culinary staff will receive in-service training on kitchen cleanliness and sanitation. a. All culinary staff will receive in-service training specific to: i. Food bin lids under the prep area will be cleaned regularly. ii. Hood vents above the grills/stove and vent above the dishwasher will be removed and cleaned at least weekly or more frequently if needed. iii. The interior microwave will be cleaned daily and/or as it becomes soiled. iv. The bottom shelf of the freezer on the service line will be cleaned weeky or more frequenly if needed. 2. To ensure compliance with #1 checks will be completed by Executive Chef, Dining Room Supervisor, or designee. 3. To ensure compliance with: i. #1.a.i,iii,iv above daily checks will be completed by Executive Chef, Dining Room Supervisor, or designee. ii. #1.a.ii above weekly checks will be completed by Executive Chef, Dining Room Supervisor, or designee. 4. Executive Chef, Dining Room Supervisor, or designee will be responsible for ensuring corrections are completed and monitored. OAR 333-150-0000 -Cleanliness and Sanitation”