The findings of the kitchen inspection, conducted 01/18/23, 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, Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.

The findings of the first revisit to the kitchen inspection survey of 01/18/23, conducted 04/12/23 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, interview and record review, it was determined the facility failed to ensure the main kitchen and memory care kitchenette were clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

1. On 01/18/23 at 2:00 pm, the main kitchen was observed to need cleaning and repair in the following areas:

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

* Floor throughout the kitchen;

* Ice machine;

* Convection oven;

* Stainless steel upper and lower shelves throughout the kitchen;

* Plate storage wells; and

* Caulking between the stainless steel table and backsplash in the dish wash area.

b. The following areas and equipment were in need of repair:

* The facility failed to ensure the high temperature warewasher was operated according to the data plate minimum wash temperature of 140 degrees F.

On 01/18/23 between 2:35 pm and 3:37 pm, several observations of the wash temperature, showed the temperature registered between 131.7 degrees F and 135.4 degrees F.

On 01/18/23 at 3:49 pm, review of the temperature log and interview with Staff 3 (Dishwasher), confirmed the warewasher was not noted to have reached the minimum wash temperature listed on the machine's data plate from 01/01/23 through 01/18/23.

Staff 2 (Chef) was immediately notified and confirmed he would contact the service vendor for repairs.

* Bottom door of the convection oven would not close properly; and

* Drain underneath the soda dispenser was backed up and filled with black liquid.

2. On 01/18/23 at 3:55 pm the memory care kitchenette was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, and debris was observed on, inside or underneath the following:

* Cabinet doors, shelves and drawers throughout the kitchen and;

* Drain underneath sink.

b. The following areas were in need of repair:

* Wooden panel in front of sink was warped and underlayer was exposed in some areas making the area uncleanable; and

* Drawer front missing on cabinet next to steam table.

The need to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (General Manager) on 01/18/23. She acknowledged the findings.

a. Each cited item has been cleaned/corrected to correct the rule violation affecting all residents.

Operations Leader reviewed the community's Food Handling Policy with all Food & Beverage team members.

A Sanitation Inspection Form has been established for the community and will be completed by a different team member on a monthly basis. The monthly Sanitation Inspection form will be reviewed by the Chef, who will review the findings and any plans with the General Manager/designee at the weekly 1:1 GM/Chef meeting and documented using the established meeting agenda template.

The General Manager is responsible to see that the corrections are completed and monitored.      

b.  The cited warewasher has been reviewed by EcoLab to be a low temperature warewasher.  It was confirmed with the manufacturer that the warewasher has been placed in low temperature mode and sanitizer being used meets standards for cleanliness. Signage has been placed to reflect that the washware machine is a low temperature model. Water temperatures will be recorded by dishwasher once per meal period and reviewed by Chef/designee daily to ensure appropriate temperature is above 120 degree F.  This information will be also rewiewed in weekly 1:1 GM/Chef Meetings and documented using the established meeting agenda template.  The General Manager is responsible seeing that the corrections are completed and monitored.  

c.  The repairs that were needed to the convection oven and drains in the kitchen have been corrected by the Plant Operations Department.  The Food & Beverage Department has been trained on how to look for areas of repair and report these needs using the communities estabished work order system of TELs.  The Chef will do a monthly walk through of the kitchen to identify physial plant and equipment concerns. These TELs work orders will be reviewed in weekly 1:1 GM/Plant Operations meeting and documented using the established meeting agenda template.        

Based on observation and interview, it was determined the facility failed to ensure it  complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a medical grade face masks while in the facility except when the employee is alone in a closed room.

Observations made in the main kitchen during the survey revealed multiple dietary staff failed to wear a medical grade face mask and revealed multiple instances where staff failed to wear their face mask properly, exposing their nose, or nose and mouth.

The observations and the need to ensure staff wore medical grade face masks appropriately while in the facility was reviewed with Staff 1 (General Manager) on 01/18/23. She acknowledged the findings.

All current and furture team members will be assigned and complete Relias Training that includes:

Infection Control Essential Practices

Infection Control Isolation and Cohorting

Personal Protective Equipment

Transmission-Based Precautions

All Staff retrained on proper donning and doffing of PPE.

The ICP/General Manager will ensure that team members are wearing their masks by doing unplanned walkthrough of community to ensure that team members are wearing the proper personal protective equipment.

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.

Reference POC for tag C240

Based on observation and interview, 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 C295.

Reference POC for tag C295