The findings of the kitchen inspection, conducted 07/18/24, 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 revisit to the kitchen inspection of 07/18/24, conducted 09/27/24, 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 second re-visit to the kitchen inspection of 07/18/24, conducted 11/26/24, 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 third revisit to the kitchen inspection of 09/27/24, conducted 01/31/25, 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, Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.

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

Observation of the main facility kitchen and the unit kitchenettes were reviewed on 07/18/24 from 10:20 am through 2:00 pm and revealed the following deficient practices:

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:

* Kitchen drain under prep area;

* Ceiling vents and light fixtures;

* Removable hood vents;

* Open shelving in prep area;

* Counter top mixer;

* Table holding slicer;

* Large can opener base and housing;

* Industrial slicer;

* Rack shelving in walk in cooler;

* Interior of reach in deli cooler;

* Sides of fryer and grill top;

* Metal racks storing clean dishes and service supplies;

* Walk in cooler floor;

* Unit kitchenette ovens;

* Unit kitchenette reach in refrigerators; and

* Walk in ceiling.

b. The following areas needed repair:

* Reach in cooler door seal broken/missing;

* Large accumulation of dust/dirt/debris on the walk in cooler fans and cage.

* Reach in refrigerator in south kitchenette reading at 62 degrees.

* Metal racks in reach in cooler next to tray line with rusted racks.

c. Multiple food items/packages/containers found in walk in, reach in deli fridge and reach in cooler near the line with food items not dated, labeled, or uncovered and exposed to potential contamination.

d. Multiple kitchen staff observed to prepare foods or handle clean dishes/equipment without hair or facial hair effectively restrained.

e. Reach in refrigerator in North unit did not have a thermometer to monitor that food was stored at appropriate temperatures. A container of Ensure for a resident and a container of cream cheese along with beverages were stored in this refrigerator.

f. Facility was using a chlorine based surface sanitizer but did not have the appropriate chemical testing strips to validate correct concentration for chemicals to effectively sanitize surfaces.

g. Kitchen staff not washing hands when going from washing dirty dishes to handling clean dishes. Staff was observed to exit kitchen and did not wash hands upon returning to kitchen.

At 1:30 pm Staff 1 (Executive Director) and Staff 2 (Dietary Manager) were informed of above areas in need of correction and they acknowledged the identified areas.

A) The following areas will be added to the weekly cleaning task list:

* Kitchen drain under prep area;

* Ceiling vents and light fixtures;

* Removable hood vents;

* Open shelving in prep area;

* Counter top mixer;

* Table holding slicer;

* Large can opener base and housing;

* Industrial slicer;

* Rack shelving in walk in cooler;

* Interior of reach in deli cooler;

* Sides of fryer and grill top;

* Metal racks storing clean dishes and service supplies; * Walk in cooler floor;

* Unit kitchenette ovens;

* Unit kitchenette reach in refrigerators; and

* Walk in ceiling.

DSD (Dining Services Manager) is responsible to ensure

task lists are turned in and completed weekly. ED to conduct audit monthly.

B)

* Reach in cooler door seal will be replaced

* Large accumulation of dust/dirt/debris

on the walk in cooler fans and cage.- Added to TELs for monthly cleaning

* Reach in refrigerator in south

kitchenette reading at 62 degrees.

* Metal racks in reach in cooler next to

tray line with rusted racks will be replaced

C) Multiple food items/packages/containers found in walk in, reach in deli fridge and reach in cooler near the line with food items not dated, labeled, or uncovered and exposed to potential contamination-

         Dietary team to receive in-service on proper storage and dating of items in kitchen. DSD to conduct audit weekly and ED to audit monthly.

D) Multiple kitchen staff observed to prepare foods or handle clean dishes/equipment without hair or facial

hair effectively restrained.

       Dietary team to receive in-service regard proper hair restraints. DSD to ensure team members are following proper hair restraints at all times.

e. Reach in refrigerator in North unit did

not have a thermometer to monitor that

food was stored at appropriate

temperatures. A container of Ensure for

a resident and a container of cream

cheese along with beverages were

stored in this refrigerator.

        Thermometer to be purchased and installed in North kitchenette refrigerator. Staff to be in-serviced that personal items are not stored in resident refrigerators at next staff meeting as well as appropriate food storage of resident items.

f. Facility was using a chlorine based

surface sanitizer but did not have the

appropriate chemical testing strips to

validate correct concentration for

chemicals to effectively sanitize

surfaces.

    Proper chemical strips ordered.

g. Kitchen staff not washing hands when

going from washing dirty dishes to

handling clean dishes. Staff was

observed to exit kitchen and did not

wash hands upon returning to kitchen.

       Dietary staff will be in-serviced on appropriate handwashing procedures. DSD to ensure observations of handwashing and instruct team to conduct as needed.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the main facility kitchen and the unit kitchenettes were reviewed on 09/27/24 from 12:30 pm through 2:30 pm and revealed the following deficient practices:

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:

* Ceiling vents and light fixtures;

* Open shelving in prep area;

* Large can opener base and housing;

* Rack shelving in walk in cooler;

* Flooring under metal racks in walk in cooler;

* Flooring in freezer;

* Sides of fryer and grill top;

* Flooring beside/under fryer;

* Metal shelving next to stove/grill;

* Walk in ceiling and cooling fans/fan cages;

* Fan blades and cages throughout kitchen areas.

* Unit kitchenette reach in refrigerators; and

* Unit kitchenette ovens.

b. The following areas needed repair:

* Reach in cooler door seal broken/missing; and

* Large accumulation of dust/dirt/debris on the walk in cooler fans and cage.

c. Salad dressing containers in reach in cooler used for salad bar did not contain labels/dates and were stored greater than 24 hrs.

At 2:00 pm Staff 1 (Executive Director) was informed of above areas in need of continued correction and they acknowledged the identified areas.

The following areas to be cleaned by dietary staff:

* Ceiling Vents

* Rack shelving in walk in cooler

*Flooring under racks in walk-in cooler

*Flooring in freezer

*Metal shelving next stove/grill

*Walk in cooling fans and cages

*Fan blades and cages

Light covers to be replaced.

Fryer and surrounding area to be cleaned by cook after each use vs current weekly schedule.

Housekeeping team reminded to clean kitchenettes weekly at Housekeeping meeting 10/9. ED to inspect weekly.

Large can opener base has been replaced. Reach in fridge door seal to be replaced.

All foods will be stored with date if being stored greater than 24 hours.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the main facility kitchen and the unit kitchenettes on 09/27/24 from 1:30 pm through 3:00 pm noted the following:

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

* Bottom shelves in prep area;

* Large can opener;

* Rack shelving in walk in cooler;

* Flooring under metal racks in walk in cooler;

* Sides of fryer/steamer and grill top next to fryer;

* Flooring beside/under/behind fryer;

* Walk in cooler ceiling and light fixture; and

* Fan blades and cage above main food prep area.

At 1:45 pm Staff 1 (Regional Director of Operations)  and Staff 2 (Dietary manager) were informed of above areas in need of continued correction and they acknowledged the identified areas.

The bottom shelves in prep area were cleaned as well as the large can opener were cleaned and sanitized  

Rack shelving and flooring under metal racks in the walk-in cooler were powerwashed and put back in place on 12/17/24.  This task was added to the monthly sanitation checklist.  

The fan cover in the walk-in cooler was removed, the fan cleaned on 12/6/24.

The fryer and grill were pulled out to clean the flooring underneath and the sides of the fryer and grill top.  This was completed on 12/23/24.  This deep cleaning task was added to the monthly sanitation checklist.  

Sanitation checklists were updated to reflect a more comprehensive approach.  Kitchen staff were trained to this updated checklist and routines the week of 12/23/24.  

Based on interview and observations, 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 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 C240.

Sanitation checklists will be reviewed weekly by the Dining Services Director and submitted to the Executive Director.  

The Executive Director will spot audit kitchen and kitchenettes weekly, referencing the cleaning checklists.  

Regional Director will review the status of the kitchen at least quarterly to ensure proper maintenance and sanitation.   

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 C 240.

see C 240

Based on observations and interviews, 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.

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.