Rock of Ages Mennonite Home.

“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 C160, C420, C422, C513, C515, C555, and H1518. This deficiency is related to Tags C160, C420, C422, C513, C515, and C555, and the corrective actions outlined under those tags will address the concerns identified. Interim measures have been implemented, including ensuring residents are wearing call pendants. Staff have been educated on safety expectations. The Administrator/ Resident Care Manager (RCM) will monitor compliance through routine safety audits to ensure sustained compliance.”

“Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. Findings include, but are not limited to: The facility was a memory care community which was home to 21 residents who were all diagnosed with some type of dementia and who experienced various degrees of cognitive decline and confusion. During a tour of the facility on 03/10/26 at 12:25 pm, multiple closets and storage rooms were found to be unlocked, and they contained potentially dangerous materials or objects as follows: * A closet where art supplies were stored (near room 2) contained a container of scissors; * A utility closet across from the beauty shop contained two bottles of liquid laundry detergent and boxes of powdered laundry detergent; and * A bank of wooden built-in cabinets near the med room contained a pair of surgical scissors and a variety of chemical medical supplies (mouthwash, antiseptics, etc.). The unsecured materials and scissors represented conditions that could threaten the health, safety, or welfare of residents. The need to exercise reasonable precautions by securing potentially dangerous items was discussed with Staff 1 (Administrator) on 03/10/26 at 1:40 pm. She acknowledged the unsecured areas. Upon identification of the concern, all chemicals, sharp objects, and hazardous items were immediately removed from unsecured areas and placed in locked cabinets in designated staff areas, and all resident-accessible areas were inspected to ensure no harmful items were accessible. The facility has implemented a policy requiring that all chemicals and sharp objects be always secured in locked cabinets or areas inaccessible to residents, and staff are responsible for identifying and properly securing any potentially hazardous items immediately after use. All staff, including caregivers and med passers, will be educated on this policy and safety expectations by 05/10/26, and this training will be included in new employee orientation. The Administrator/Resident Care Manager (RCM) is responsible for ensuring ongoing compliance, and this plan will be fully implemented by 05/10/26.”

“Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation contained all required elements, was dated, and indicated who was involved in the evaluation process, for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2025 with diagnoses including dementia. The facility provided three documents that it used to gather information about a new resident: a seven-page evaluation titled “Rock of Ages Memory Care Facility,” the “OR/WA: Initial and Annual Licensed Nursing Assessment,” and the facility “Personal Interest Questionnaire.” The following was identified: a. None of the documents indicated who was involved in the evaluation process, and only the nursing assessment included a date. b. The evaluations failed to address the following elements: * Name, pronouns, and gender identity; * Customary routines regarding eating and bathing; * Traditions; * Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; * How the person copes with change or challenging situations; * Ability to manage medications; * Housework and laundry; * Transportation; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration; * Recent losses; * Unsuccessful prior placements; and * Elopement risk or history. The need to ensure the initial evaluation contained information addressing all required elements was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 03/11/26 at 11:00 am. They acknowledged the information that was lacking. Following the survey finding, the facility conducted a review of current resident move-in evaluations and updated them to include all required elements, including residents’ routine meals, frequency of ADL assistance, personal traditions, date of last physician visit, frequency of medical follow-ups, and coping mechanisms for stress, ensuring all assessments include a signature and date. The move-in evaluation packet has been revised to include these elements, and a process has been implemented to ensure all assessments and care plans are completed prior to move-in; for emergency placements, assessments and care plans will be completed within 24 hours of admission. The Administrator, Memory Care Nurse, and Resident Care Manager (RCM) is responsible for oversight, and this plan will be fully implemented by 05/10/26.”

“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. This Rule is not met as evidenced by: 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, for 1 of 3 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the MCC in 08/2021, with diagnoses including dementia, hypertension, and osteoporosis. Review of Resident 3's service plan, dated 01/06/26, and temporary care plans, observations of the resident, and interviews with staff revealed the service plan was not reflective or lacked clear direction to staff in the following areas: * Use of side rails on the resident’s bed; * Hospice services received; and * History of suicidal ideations and behaviors Observations during the survey confirmed Resident 3 had 1/2 rails on both sides of the bed. Hospice visit notes were reviewed in the resident’s clinical record, confirming Resident 3 was receiving hospice services. An RN assessment, dated 01/29/26, included the statement, “[Resident 3] requires close supervision and ongoing monitoring to help prevent and respond to suicidal thoughts, verbalizations, and behaviors.” These concerns were verified by Staff 2 (RN) in an interview on 03/11/26 at 1:05 pm. On 03/12/26 at 12:45 pm, the need to ensure service plans were reflective of current resident care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings. In response to the cited deficiency, the facility conducted a review of current resident service plans to ensure they accurately reflect individual needs, including hydration and eating preferences with intake amounts, past and current activity interests, and behaviors including identified stressors and appropriate coping interventions, and updates were made as needed. The move-in evaluation packet and service plan process have been revised to include these required elements and to ensure that all identified needs are consistently reflected in the service plan. The Administrator, and Resident Care Manager (RCM) are responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.”

“Based on interview and record review, it was determined the facility failed to determine, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition, ensure weekly progress was noted until the condition was resolved, and monitor each resident consistent with his or her evaluated needs and service plan, for 1 of 1 sampled resident (#3) who experienced multiple falls. Findings include, but are not limited to: Resident 3 was admitted to the MCC in 08/2021, with diagnoses including dementia, hypertension, and osteoporosis. Review of Resident 3’s clinical record revealed the following: a. The resident experienced four documented falls between 12/10/25 and 03/10/26. Following each fall, the facility failed to determine and document what actions or interventions were needed for the resident, communicate the interventions to staff, and note weekly progress until the condition was resolved. b. The service plan listed the following interventions for fall prevention: * Encourage [him/her] to use walker; * Keep light on in the bathroom at night; * Make sure [he/she] is wearing sandals or older gray shoes; and * Use alarm in bed and in wheelchair. There was no documented evidence the facility monitored the fall interventions following each fall to determine if the interventions were effective or if new interventions needed to be developed. On 03/11/26 at 1:05 pm, Staff 2 (RN) was interviewed regarding Resident 3’s falls. Staff 2 acknowledged the facility did not identify interventions, monitor the resident’s progress, or monitor the service-planned fall interventions for effectiveness following each fall. On 03/12/26 at 12:45 pm, the need to determine, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition, ensure weekly progress was noted until the condition was resolved, and monitor the resident’s fall interventions for effectiveness was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings. Following the survey finding, the facility reviewed recent fall and incident records to ensure appropriate monitoring and documentation were completed. The facility has implemented a policy and checklist for falls, incidents, and return from ER to ensure a consistent process that includes completion of an initial incident report, initiation of alert charting and monitoring, and a final progress note indicating resolution and evaluation of interventions for effectiveness. The process also includes implementation and review of fall interventions to determine if they are effective and require revision. All staff will be educated on these requirements by 05/10/26, including expectations for timely documentation, ongoing monitoring, and follow-up after incidents, and this will be included in new employee orientation. The Administrator, Nurse, Resident Care Manager (RCM) are responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.”

“Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC), keep a complete written fire drill record, and provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Review of fire and life safety records, dated 10/2025 through 03/2026, revealed the following: a. Two of three fire drill records did not indicate whether residents were evacuated or relocated during fire drills. In an interview on 03/11/26 at 10:50 am, Staff 5 (Chief Operations Officer) acknowledged residents were not being relocated during fire drills. b. Fire drill records lacked consistent documentation of the following components: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. c. Fire and life safety training was not being provided to staff on alternate months, as required. In an interview on 03/12/26 at 12:45 pm, the need to include residents in fire drills, keep a complete written fire drill record, and provide fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings.”

“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 C252, C260, and C270. This deficiency is related to Tags C252, C260, and C270, and the corrective actions outlined under those tags will address the concerns identified. Staff have been educated on requirements for assessments, service plans, and post-incident monitoring. The Administrator/Resident Care Manager (RCM) will monitor compliance through routine record audits to ensure sustained compliance.”

“Based on interview, it was determined the facility failed to instruct residents within 24 hours of admission and re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: In an interview on 03/11/26 at 10:50 am, Staff 5 (Chief Operations Officer) stated the facility had not been providing instruction to residents on fire and life safety topics at admission and re-instruction annually. No records were provided. There was no documented evidence residents received fire and life safety instruction within 24 hours of admission, and were reinstructed at least annually, thereafter. On 03/12/26 at 12:45 pm, the need to provide and document fire and life safety instruction for residents within 24 hours of admission and at least annually thereafter was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings. In response to the cited deficiency, the facility conducted a review of current residents to ensure fire and life safety instructions were provided and documented, and any missing education was completed. The facility has implemented a process to provide fire and life safety instructions to all residents upon admission and annually thereafter, with documentation maintained in the resident's record. A tracking system has been established to ensure annual education is completed in a timely manner for each resident. The Administrator will conduct monthly audits of resident records to ensure compliance with admission and annual training requirements. The Administrator is responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.”

“Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) were kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 03/10/26 at 12:25 pm. The following was identified: * There were corners of the baseboard in the hallways that were gouged, exposing bare wood; * Doors and doorframes of resident rooms 3, 4, 5, 8, and 16 were scraped, exposing bare wood; and * There was a large brown spot/stain on the carpet in front of the courtyard entry door on the front side of the unit (near the TV/fireplace common area). The areas needing cleaning and repair were toured with Staff 1 (Administrator) on 03/10/26 at 1:40 pm. She acknowledged the areas needing cleaning and repair. In response to the cited deficiency, the facility addressed environmental concerns by cleaning-stained carpets, painting wooden door frames and doors, and repairing dents in walls to ensure all areas are in good condition. The facility has implemented a routine maintenance and housekeeping process to ensure carpets, doors, and surrounding areas are maintained in good repair and free from damage or excessive wear. The Administrator will conduct monthly environmental rounds to ensure ongoing compliance, with any identified issues addressed promptly. The Administrator is responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.”

“Based on observation and interview, it was determined the facility failed to provide a lockable storage space (e.g., drawer, cabinet, or closet) in each resident unit for the safekeeping of a resident's small valuable items and funds. Findings include, but are not limited to: During an interview and a tour of his/her apartment on 03/11/26 at 2:40 pm, Resident 1 reported the apartment did not have a lockable storage space. The surveyor did not observe a lockable storage space in Resident 1’s apartment. In an interview on 03/11/26 at 2:50 pm, Staff 1 (Administrator) confirmed none of the resident units had a lockable storage space. The need to provide a lockable storage space in each resident unit was reviewed with Staff 1, Staff 2 (RN), Staff 3 (Resident Care Manager), and Staff 5 (Chief Operations Officer) on 03/12/26 at 1:50 pm. They acknowledged the findings. Following the survey finding, the facility ensured that each resident apartment is equipped with functional lockable storage by placing lockboxes in all resident rooms and verifying that each unit has appropriate lockable storage available. The facility has implemented a process to ensure all new admissions are provided with lockable storage upon move-in, and that lockboxes remain functional and in good condition. The Administrator is responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.”

“Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers and failed to provide a manually operated emergency call system in each toilet and bathing facility used by residents and visitors. Findings include, but are not limited to: The facility was toured on 03/10/26 at 12:25 pm. The following was identified: a. During an interview and a tour of Resident 1’s apartment, no call system was observed in the resident’s bathroom or living space. When asked how s/he would call for assistance when in the unit, Resident 1 stated s/he did not know. In an interview on 03/11/26 at 2:50 pm, Staff 1 (Administrator) stated the facility provided each resident with a call pendant that connected to the facility’s call system and staff pagers. During the survey, from 03/10/26 through 03/12/26, residents were not observed wearing pendants. In an interview on 03/12/26 at 11:24 am, Staff 9 (CG) acknowledged that, though residents were provided call pendants, most did not wear them either because they preferred not to and kept removing them, or the resident’s pendant was misplaced somewhere in the resident’s apartment. The observations and interview with the CG were shared with Staff 1 on 03/12/26 at 11:40 am. She acknowledged the facility needed to ensure residents wore their pendants. b. Two common-use bathroom/spa rooms did not have a manually operated emergency call system. In an interview on 03/11/26 at 2:50 pm, Staff 1 acknowledged the two common bathrooms did not have a manually operated emergency call system. The need to ensure the facility had a call system that connected resident units to the care staff center or staff pagers and a manually operated emergency call system in each toilet and bathing facility used by residents and visitors was reviewed with Staff 1, Staff 2 (RN), Staff 3 (Resident Care Manager), and Staff 5 (Chief Operations Officer) on 03/12/26 at 1:50 pm. They acknowledged the findings. The facility has identified the need to upgrade the current call light system and is in the process of coordinating with vendors for installation of a new system. In the interim, to ensure resident safety and timely response to needs, staff are ensuring residents are wearing their call pendants; for residents who choose not to wear them or are unable to do so, staff are providing increased monitoring through frequent checks. The Administrator will oversee this process and ensure continued compliance until the new system is implemented”

“Based on observation and interview, it was determined the facility failed to ensure resident units had entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. Findings include, but are not limited to: During an interview and a tour of his/her apartment on 03/11/26 at 2:40 pm, Resident 1 reported s/he did not have a key to the unit. S/he said it seemed odd that s/he was not given a key to their apartment and had “wondered about that.” In an interview on 03/11/26 at 2:50 pm, Staff 1 (Administrator) stated residents were not given a key to their unit unless they asked for one. The facility failed to provide each resident with a key to their unit as required. The need to ensure residents were provided a key to their unit was reviewed with Staff 1, Staff 2 (RN), Staff 3 (Resident Care Manager), and Staff 5 (Chief Operations Officer) on 03/12/26 at 1:50 pm. They acknowledged the findings. In response to the cited deficiency, the facility verified that all current residents have been offered and provided a key to their apartment, and this was documented, with any missing keys issued immediately. The facility has implemented a process to ensure each resident is provided a key at move-in in accordance with resident rights, and this will be documented in the move-in process. Residents who choose not to carry or use their key may keep it in their apartment per their preference. The Administrator is responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.”

“Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements, including name, pronouns, and gender identity, for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to C 252. N/A”

“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 03/1/0/26 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Commercial can opener – blade and surrounding areas with black/brown matter build up; * Upright refrigerator at end of service line – interior with drips/spills, wet/unclean towels on bottom shelf; * Side of grill/stove – food drips/spills/splatters; * Shelf below toaster – build up of black matter/grease/debris; * Wall behind toaster – food splatters; and * Wall behind dishwasher and below counter – build up of black matter/drips/spills. Improper food storage included: * Food items in both walk in refrigerator and freezer – not labeled, not dated, not securely closed to prevent contamination/ food items included: fruit in a bowl, corn tortillas, rice, lunch meat, sliced cheese, feta cheese, shredded cheese, frozen breaded meat products, meat patties; and *Walk in freezer – boxes and food debris on floor. Other concerns included: * Colored cutting boards – finish worn and scored; and * Dishwashing staff lacked use of hair restraint. The areas of concern were observed and discussed with Staff 1 (Dietary Manager) and discussed with Staff 2 (Chief Operating Officer) on 03/10/26. The findings were acknowledged at 12:45 pm by Staff 1 and Staff 2. 1.• All identified areas and equipment were immediately cleaned and sanitized, including the can opener, refrigerator, grill/stove, shelves, walls, and dishwasher area. • A new commercial can opener and refrigerator have been purchased. • Wet/soiled towels were removed and proper storage practices reinforced. • All improperly stored food items were discarded or properly labeled, dated, and sealed immediately. • Walk-in refrigerator and freezer were cleaned and organized; debris and boxes were removed from the floor. • Worn cutting boards have been removed from service and replaced. • Dishwashing staff were immediately provided with and required to wear proper hair restraints. 2. • A labeling and dating policy has been reinforced requiring all food items to be labeled with name and date opened/prepared. • Staff were re-trained on proper food storage, covering, and contamination prevention. • Designated storage areas have been established to keep floors clear at all times. • A routine inspection schedule for kitchen tools and equipment has been implemented to ensure items remain in good condition. • Staff have been re-trained on hygiene and food safety requirements, including mandatory use of hair restraints. 3. • A daily and weekly cleaning schedule has been implemented for all kitchen equipment and surfaces. • A cleaning log has been implemented and must be completed at the end of every shift. 4. The Dietary manager will be responsible to ensure the corretions are completed and being monitored. 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. 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 kitchen inspection, conducted 03/26/24, 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 03/26/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the first re-visit to the annual kitchen inspection of 03/26/24, conducted 05/14/24, 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 first re-visit to the annual kitchen inspection of 03/26/24, conducted 05/14/24, 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 kitchen practices and protocols were in compliance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 03/26/24 at 11:05 am, the kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris, dirt, grease, black matter and/or dust was observed on the following: * Commercial can opener blade; * The counter top holding microwave; * Lower shelves throughout the kitchen: * Hood vents above stove/grill; * Stainless steel wall behind stove/grill; * Exterior of flour and sugar bins; and * Side of stove. b. Other areas of concern included: * Multiple containers of food items in the refrigerator at the end of the steam table, were not labeled with dates or contents; * The walk in refrigerator had a container of lettuce undated and a mixer bowl of unknown contents which was not labeled or dated; * Pasteurized eggs were not available, the vendor provided a substitute which was not pasteurized, if the facility was unable to return the eggs they must be fully cooked when served to residents; * Staff were not washing hands between glove changes; and * Some staff not wearing hair restraints. The areas of concern were observed and discussed with Staff 1 (Kitchen Supervisor) and discussed with Staff 2 (Executive Director) on 03/26/24. The findings were acknowledged. Based on observation and interview it was determined the facility failed to ensure kitchen practices and protocols were in compliance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 03/26/24 at 11:05 am, the kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris, dirt, grease, black matter and/or dust was observed on the following: * Commercial can opener blade; * The counter top holding microwave; * Lower shelves throughout the kitchen: * Hood vents above stove/grill; * Stainless steel wall behind stove/grill; * Exterior of flour and sugar bins; and * Side of stove. b. Other areas of concern included: * Multiple containers of food items in the refrigerator at the end of the steam table, were not labeled with dates or contents; * The walk in refrigerator had a container of lettuce undated and a mixer bowl of unknown contents which was not labeled or dated; * Pasteurized eggs were not available, the vendor provided a substitute which was not pasteurized, if the facility was unable to return the eggs they must be fully cooked when served to residents; * Staff were not washing hands between glove changes; and * Some staff not wearing hair restraints. The areas of concern were observed and discussed with Staff 1 (Kitchen Supervisor) and discussed with Staff 2 (Executive Director) on 03/26/24. The findings were acknowledged. a. Action: ~ All food spills, splatters, and debris have been cleaned. a. Avoid happening again: ~ A regular cleaning schedule has been implemented for the following areas; * Commercial can opener * Counter tops * Lower shelves * Hood vents above stove/grill * Stainless steel wall behind stove/grill * Sides of stove/grill * Exterior of flour and sugar bins ~ In addition checklists for cooks and servers that must be completed before end of shift, on a daily basis, have been made. ~ Kitchen supervisor is responsible for seeing and making sure tasks are done daily. b. Action: ~ Have posted signs to reinforce labeling things before storing them. b. Avoid happening again: ~ Labeling has been added to the daily checklist for cooks. ~ Kitchen supervisor will be in charge of making sure they are completeing checklist daily. b. Action: ~ Pasturized eggs were ordered, and remaining unpasturized eggs were fully cooked before being served to residents. b. Avoid Happening again: ~ Made contact with vendor to make sure that any substitutions must be pasturized. ~ Kitchen supervisor is responsible for not acceptin non pasturized eggs from vendor. b. Action: ~ Required staff further training on cross contamination, and improper glove use and hair restraints. b. Avoid happening again: ~ Had staff study over the rules and printed a quick reference of cross contamination. ~ Posted signs implementing the need for hair restraints. ~ Kitchen supervisor is in charge of monitering glove use and hair restraint use. a. Action: ~ All food spills, splatters, and debris have been cleaned. a. Avoid happening again: ~ A regular cleaning schedule has been implemented for the following areas; * Commercial can opener * Counter tops * Lower shelves * Hood vents above stove/grill * Stainless steel wall behind stove/grill * Sides of stove/grill * Exterior of flour and sugar bins ~ In addition checklists for cooks and servers that must be completed before end of shift, on a daily basis, have been made. ~ Kitchen supervisor is responsible for seeing and making sure tasks are done daily. b. Action: ~ Have posted signs to reinforce labeling things before storing them. b. Avoid happening again: ~ Labeling has been added to the daily checklist for cooks. ~ Kitchen supervisor will be in charge of making sure they are completeing checklist daily. b. Action: ~ Pasturized eggs were ordered, and remaining unpasturized eggs were fully cooked before being served to residents. b. Avoid Happening again: ~ Made contact with vendor to make sure that any substitutions must be pasturized. ~ Kitchen supervisor is responsible for not acceptin non pasturized eggs from vendor. b. Action: ~ Required staff further training on cross contamination, and improper glove use and hair restraints. b. Avoid happening again: ~ Had staff study over the rules and printed a quick reference of cross contamination. ~ Posted signs implementing the need for hair restraints. ~ Kitchen supervisor is in charge of monitering glove use and hair restraint use. There are no detail notes for this visit.”

“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. Refer to plan of correction for C240 Refer to plan of correction for C240 There are no detail notes for this visit.”