The findings of the kitchen inspection, conducted 04/11/24 - 04/12/24, 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 re-visit to the kitchen inspection of 04/12/24, conducted 07/03/24, 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.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

The findings of the second revisit to the kitchen inspection of 04/12/24, conducted 09/16/24, 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 observations and interviews, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:  

Observation of the kitchen on 04/11/24 at 10:30 am through 12:30 pm, and on 04/12/24 from 11:30 am through 2:00 pm revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine;

* Kitchen drains;

* Electrical outlets and light switches;

* Ceiling fire vents and light fixtures;

* Wall behind prep area where knives were stored;

* Stove top, oven doors, interior, and exterior;

* Industrial mixer and slicer;

* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under and between equipment;

* Rack shelving in dry good storage;

* Under and behind shelving in dry good storage;

* Exterior and interior of reach in refrigerators and freezers;

* Interior of food cart; and

* Cabinet under sink in memory care kitchenette.

b. The following areas were in need of repair:

* Section of caulking by dish machine with black debris build up;

* Small refrigerator in Memory Care unit with frost build up;

* Cabinet under sink in Memory Care unit with damage to wall (hole in concrete) and:

* Section of base board missing in Memory Care kitchenette.

c. Surface sanitizer strips were not stored properly and were visibly damaged.

d. Multiple food items were found not dated when opened. Some items were found past seven days and should have been discarded. Whole shell eggs were found stored above RTE (ready to eat) food items causing potential for cross contamination.

e. Multiple containers of bulk dry goods had cups or scoops stored in them.

f. Large bucket of used/dirty cooking oil found stored without a cover.

g. Some items in refrigerator weren't covered/protected from potential contamination.

h. Multiple staff observed coming in kitchen area without washing hands or performing hand hygiene and without hair restrained as required. Two kitchen employees were observed preparing food/handling clean equipment without facial hair restrained.

i. Caregiving staff assisting residents with their meals did not have aprons on to prevent possible contamination from their clothing during meals.

j. Kitchen staff returned from a break without washing hands. They were also observed to drink from a canned beverage and not wash hands. Cook was observed to wash hands in a prep sink and dry hands on a cloth towel.

k. Staff member assisting in dining room during meal service was observed to handle their phone then assist residents with beverages and meals without performing hand hygiene. The hand sanitizer dispenser in the dining room was observed not operational during the survey process.

One 04/12/24 At 1:15 pm, the surveyor reviewed with Staff 2 (Dining Service Director) areas in need of cleaning, repair and attention. S/he acknowledged areas. At approximately 1:45 pm, Staff 1 (Executive Director) was informed and acknowledged the of areas in need of correction.

1. The kitchen will receive a deep clean and an updated cleaning schedule will be put in place. Food items that are not properly covered, labeled, or dated were removed including used oil without a lid covering. Areas identified with need for repair will be repaired.

2. Dining Services staff will receive additional training on Cleaning Schedules and the QA - Storage and Sanitation Audit (includes verifying all items are covered, labeled, dated, no scoops in storage bins, etc.) Dining Services and Direct Care Staff will receive additional training on Handwashing, use of aprons, and hair/beard coverings.

3. The Dining Services Director will complete the QA - Storage and Sanitation Audit weekly per the Quality Assurance - Dining Services Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

Based on observations and interviews, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:  

Observation of the kitchen on 07/03/24 at 12:45 pm through 2:00 pm revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine;

* Kitchen drains;

* Open stainless steal shelving;

* Plate warmer;

* Interior of drawers;

* Wall behind prep area where knives were stored;

* Industrial can opener and housing;

* Industrial mixer and slicer;

* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under and between equipment;

* Can rack in dry storage;

* Exterior and interior of reach in refrigerators and freezers;

* Mini refrigerator in Memory care; and

* Cabinet under sink in memory care kitchenette.

b. The following areas were in need of repair:

* Section of caulking by dish machine with black debris build up;

* Small refrigerator in Memory Care unit with frost build up;

* Cabinet under sink in Memory Care unit with damage to wall (hole in concrete) and:

* Section of base board missing in Memory Care kitchenette.

c. Plastic coffee mugs noted heavily scored and stained.

d. Multiple food items were found not dated when opened/prepared, items stored in refrigerators or freezers not covered or completely sealed. Staff food stored with resident food items. Whole shell eggs were found stored above pre-cooked ham and other food items causing potential for cross contamination.

e. Caregiving staff assisting residents with their meals did not have aprons on to prevent possible contamination from their clothing during meals.

Staff 1 (Cook and designated Person In Charge at time of revisit) toured with surveyor and acknowledged the above findings.

1. a. all identified areas have received a deep clean, can opener is being replaced.

   b. identified areas are being repaired and mini refrigerator has been replaced.

   c. plastic coffee mugs have been replaced.

   d. all identified food items were removed and discarded.

   e. see number 2.

2. All staff receiving additional training on wearing aprons during meals and storing personal food items. Dining staff are receiving training on revised kitchen cleaning schedule.

3. The Dining Services Director will review daily on working days following the QA - Dining Services Schedule. The Executive Director will review weekly auditing the Dining Services Director.

4. The Executive Director will be responsible to ensure compliance.

Based on interview, observation, and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 240.

Refer to C240

Based on observations and interviews, 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.

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 240.

Refer to C240