The findings of the kitchen inspection, conducted 04/16/24, 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 kitchen inspection of 04/16/24, conducted 06/26/24, 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 and OARs 411 Division 57 for Memory Care Communities.

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.

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 04/16/24 at 11:05 am, the facility was observed to need cleaning in the following areas:

a. Food spills, splatters, debris, grease, dirt, dust and/or black/brown/yellow matter was observed on, underneath or behind the following:

* Floor under and behind stove/grill;

* Exterior oven doors;

* Hood vents above grill/stove:

* Sides of steamer, grill and  oven:

* Shelf beneath microwave;

* Ceiling air vents above coffee maker; and

* Flooring throughout the kitchen was cracked and stained, including corners and base coving.

The areas of concern were observed and discussed with Staff 1 (Dining Services Director) and Staff 2 (Executive Director) on 04/16/24. The findings were acknowledged.

1. All identified areas in the kitchen have been deep cleaned, and all repairs have been completed or scheduled, including receiving bids to repair or replace the kitchen floor.

2. Routine cleaning schedules for kitchen have been updated to include areas that were missing. Dietary Manager will be reviewing cleaning schedules weekly, at a minimum, and will follow up as needed. Dietary Mananger will complete a monthly kitchen sanitation audit, to include repair work needed, and ensure any deficencies will be corrected timely.

3. System will be evaluated monthly as part of the Quality Assurance and Performance Improvement process to include a review of the monthly kitchen sanitation audits.

4. Executive Director, Expressions Director and Dietary Manager will be responsible for maintaining this system

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. This is a repeat citation. Findings include, but are not limited to:

On 06/26/24 at 10:10 am, observations of the facility main kitchen identified the following:  

a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:

* Floor underneath and behind stoves/grill,

* Exterior oven doors, sides, and knobs;

* Caulking and wall plastic strip in dish machine area;

* Flooring beside ice machine;

* Floor drain under steam table;

* Pipes underneath counter and along wall in food prep area; and

* Rungs of rolling bread rack in food prep area.

b. The following areas were in need of repair:

* Flooring throughout the kitchen was cracked and stained; and

* Entry door jambs had scraped paint in multiple areas.

The areas that required cleaning and repair were observed and discussed with Staff 1 (Dietary Manager) on 6/26/24 at 10:40 am, and with Staff 3 (Executive Director) during the exit interview. The findings were acknowledged.

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

Refer to C 240.

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 C 240.

1. All C tag violations will be resolved no later than 6/15/2024.

2. To prevent recurrence, refer to systems put in place for tags C240.

3.All systems pertaining to C tags will be evaluated as part of the monthly facitlity Quality Assurance and Performance Improvement program to ensure compliance.

4. Executive Director and Expressions Director will be responsible for maintaining all systems.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240.