Footsteps at Wilsonville.

“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 10/09/25 at 10:45 pm, the facility kitchen was observed to need cleaning and repair in the following areas: * Wall behind handwashing sink – spills/splatters; * Dishwashing area – caulking and area above splash guard black matter build up; floor under counter/booster/dishwashing machine – significant build up of black matter/debris; wall underneath sink drips/splatter of brown/brown matter; hood above dishwashing machine significant black matter build up; drain below sink black matter build up; * Walk in freezer floor – frozen debris/spills; * Shelf below steamer – drips/spills; * Floor behind steamer – significant debris/matter build up; * AC units, piping, electrical boxes on wall of walkin refrigeration units – heavy build up of dust/cobwebs; * Piping, chain, electrical box on wall behind steamer – build up of dust; and * Butler kitchen – interior of microwave with splatters; bottom shelf of refrigerator with drips/spills. Other areas of concern included: * Colored cutting boards – heavily scored and finish worn off; * White cutting board – heavily stained and scored; and * Box of oranges in walk in refrigerator had several oranges that were moldy. The areas of concern were observed and discussed with Staff 1 (Food & Beverage Director) and discussed with Staff 2 (Executive Director) on 10/09/25. The findings were acknowledged.”

“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 C 240 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:”

“Based on an interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#3). Findings include, but are not limited to: A review of the signed physician order, dated 01/11/24, indicated Paxlovid 300 mg (150 mg x 2) - 100 mg dose packet. Take one packet by mouth two times daily for 10 doses. A review of Resident 3's progress notes, dated 01/12/24 to 01/18/24, indicated missed doses of Paxlovid. In an electronic communication, dated 03/26/25, Staff 1 (Administrator) acknowledged that three doses were missed. The facility's failure to carry out medication orders as prescribed was substantiated. Findings were reviewed with and acknowledged by Staff 1 via phone on 03/28/25. Based on an interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (#3). Findings include, but are not limited to: A review of the signed physician order, dated 01/11/24, indicated Paxlovid 300 mg (150 mg x 2) - 100 mg dose packet. Take one packet by mouth two times daily for 10 doses. A review of Resident 3's progress notes, dated 01/12/24 to 01/18/24, indicated missed doses of Paxlovid. In an electronic communication, dated 03/26/25, Staff 1 (Administrator) acknowledged that three doses were missed. The facility's failure to carry out medication orders as prescribed was substantiated. Findings were reviewed with and acknowledged by Staff 1 via phone on 03/28/25.”

“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 10/31/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: *Fan, which was operating, on beverage counter pointed toward service line – heavy dust buildup; * Commercial can opener – build up of debris on blade; * Food storage bins – lids and exteriors buildup of food debris; * Hood vents above cooking equipment – dust/grease build up; * Hood above dishwasher – heavy buildup of black matter; * Refrigerator next to hand washing sink – bottom shelf buildup of spills/debris; * Wall below spray hose sink in dishwashing area – black/brown matter spills/drips; * Caulking above sink in dishwashing area – buildup of black matter; * Flooring and drains underneath counters and equipment throughout the kitchen – buildup of black matter/debris; and * Lower shelving throughout the kitchen – spills/debris/splatters. Improper food storage concerns included: * Rolling cart (next to door) in walk in refrigerator – four trays of uncovered/unlabeled desserts; * Rolling cart (back wall) in walk in refrigerator – one tray of uncovered/unlabeled meat portions; and * Butler pantry – one tray of uncovered/unlabeled desserts. The areas of concern were observed and discussed with Staff 1 (Food and Beverage Director) and discussed with Staff 2 (Administrator) on 10/31/24. The findings were acknowledged. Kitchen staff meeting 11/14/24 to cover plan of correction and discuss systems in place to ensure safety and compliance.”

“OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: 1.The community will maintain compliance to the plan of correction. 2. The Culinary Director will monitor compliance by reviewing cleaning checklist and performing visual inspections. 3. The Culinary Director will assess daily, weekly and monthly checklists. 4. The Culinary director will share progress with Executive Director at weekly 1:1's. The Executive Director will perform spot checks periodically to ensure all areas are in compiance. OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. 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 08/03/23, 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 08/03/23, 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 08/03/23, conducted 11/03/23, 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. The findings of the revisit to the kitchen inspection of 08/03/23, conducted 11/03/23, 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.”

“Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.  Findings include, but are not limited to: On 08/03/23 at 11:15 am, the kitchen was observed to need cleaning in the following areas: * Floors throughout the kitchen, including floors in the walk in refrigerator & freezer had food debris, stains, accumulation of grease/dust; * Lower shelves throughout the kitchen had food debris/food spills/splatters; * The wall and floor behind the convection oven and the steamer/roaster had heavy build up of grease, dust and debris; * Pipes under the stove/grill had heavy build up of grease and dust; * The wall area under and above the shelf that stored the blenders had food splatters; * The wall with knives storage had food splatters; * The shelf below Hobart mixer and the wall behind had food debris and splatters; * The hood vents above the stove/grill had accumulation of grease/dust; * The rack shelving under the beverage station had build up of dust/debris; * The ceiling light above stove area had significant build up of dust; * The ceiling vent and light in dishroom had build up of dust; * The air conditioning units above the walk in refrigerator had heavy build up of dust, including the wall and ceiling in the same areas; and * Food storage bins had scoops in the product (panko, white sugar and oatmeal) and the outsides & lids of the bins were unclean. Food stored on rolling cart was uncovered, items included two trays of individual pudding cups, pie and cake. Memory Care steam table had tray of uncovered pudding cups stored on the shelf underneath the steam table, just a few inches off the floor. Watermelon slices and pickles were on top of the steam table uncovered. Steam table stored in a busy area of the kitchen, exposing the food to potential cross contamination. Tray of pudding cups were transported uncovered to the Memory Care dining room. Garbage can beside steam table uncovered when not in use. Kitchen staff observed not wearing hair restraints. The findings were discussed with Staff 1 (Food & Beverage Director) and Staff 2 (Executive Director) on 08/03/23. The findings were acknowledged. Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.  Findings include, but are not limited to: On 08/03/23 at 11:15 am, the kitchen was observed to need cleaning in the following areas: * Floors throughout the kitchen, including floors in the walk in refrigerator & freezer had food debris, stains, accumulation of grease/dust; * Lower shelves throughout the kitchen had food debris/food spills/splatters; * The wall and floor behind the convection oven and the steamer/roaster had heavy build up of grease, dust and debris; * Pipes under the stove/grill had heavy build up of grease and dust; * The wall area under and above the shelf that stored the blenders had food splatters; * The wall with knives storage had food splatters; * The shelf below Hobart mixer and the wall behind had food debris and splatters; * The hood vents above the stove/grill had accumulation of grease/dust; * The rack shelving under the beverage station had build up of dust/debris; * The ceiling light above stove area had significant build up of dust; * The ceiling vent and light in dishroom had build up of dust; * The air conditioning units above the walk in refrigerator had heavy build up of dust, including the wall and ceiling in the same areas; and * Food storage bins had scoops in the product (panko, white sugar and oatmeal) and the outsides & lids of the bins were unclean. Food stored on rolling cart was uncovered, items included two trays of individual pudding cups, pie and cake. Memory Care steam table had tray of uncovered pudding cups stored on the shelf underneath the steam table, just a few inches off the floor. Watermelon slices and pickles were on top of the steam table uncovered. Steam table stored in a busy area of the kitchen, exposing the food to potential cross contamination. Tray of pudding cups were transported uncovered to the Memory Care dining room. Garbage can beside steam table uncovered when not in use. Kitchen staff observed not wearing hair restraints. The findings were discussed with Staff 1 (Food & Beverage Director) and Staff 2 (Executive Director) on 08/03/23. The findings were acknowledged.”

“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. C142 Refer to C240 plan of correction C142 Refer to C240 plan of correction There are no detail notes for this visit.”