The findings of the kitchen inspection, conducted 05/09/23, 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 first revisit for the kitchen inspection on 05/09/23, conducted 06/20/23, 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 second re-visit of the annual kitchen inspection on 05/09/23, conducted 08/23/23, 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 kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the main kitchen, memory care kitchenette, food storage areas, food preparation, and food service on 05/09/23 revealed the following:

* Open packages of dry cereal stored on a shelf above clean dishes in the main kitchen food service area;

* Garbage barrels used for food disposal did not have covers available when not in use;

* Build up of food material on the grill surface and overflow drawer of the grill top;

* Sanitizer buckets with cleaning cloths were tested using test strips and were shown to have a lower concentration of sanitizing chemical than the acceptable range on the test strip instructions;

* The sanitizing solution distributed by the "Ecolab" dispenser installed above the three compartment sink was tested by kitchen staff, using the test strips, and showed the chemical sanitizer was below the acceptable range;

* Cooked fish being stored in a warm oven, prior to serving, measured 120 degrees with a probe thermometer (below the required temperature of 135 degrees Fahrenheit);

* One kitchen staff was observed without properly restrained hair while washing dishes and performing food preparation;

* The refrigerator and freezer in the memory care kitchenette had dried spills and food particles on the shelves throughout; and

* Direct care staff in the memory care unit, who were designated to also serve meals, did not have aprons to wear during food service tasks.

The following areas/items were in need of repair:

* Exposed wood surfaces, scuffs and blackened areas on the doors exiting the kitchen into the dining room;

* Exposed wood surfaces and damage to the cabinets below the coffee and juice service areas in the dining room; and

* The hot water sitting in hand washing sinks in the main kitchen needed an extended period of time, in excess of three minutes, for the water to get hot (temperature obtained was a maximum of 112 degrees Fahrenheit).

During an interview on 05/09/23, Staff 2 (Human Resources Manager) provided copies of food handler certification cards for kitchen staff. A review of the records showed ten kitchen staff did not have a current food handler's card. Staff 2 acknowledged the findings.

At 11:15 am, the above areas were discussed with Staff 1 (Kitchen Manager) and Staff 3 (Administrator). They acknowledged the findings.

Care staff and house keeping given instruction to deep clean kitchen 1x per week. Care staff to keep up with general daily cleaning tasks such as cleaning up spills, sweeping, mopping, sanitizing countertops and high contact areas.

Full body aprons ordered for care staff whom are serving food. Staff to be trained on cleanthiness and expectations of daily upkeep of kitchen and common areas.

Weekly

Kora Greer- Memory Care Administrator

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

a. Observations of the main kitchen, memory care kitchenette, food storage areas, and food preparation on 06/20/23 revealed the following:

* Garbage barrels used for food disposal (in the main kitchen and the memory care kitchenette) did not have covers available when not in use;

* Staff food was stored in the refrigerator used for resident food in the memory care kitchenette;

* Food items found in the refrigerator and freezer in the memory care kitchenette were not properly covered, labeled and/or dated;

* The interior and exterior oven and countertops in the memory care kitchenette had dried spills and food particles; and

* Direct care staff in the memory care unit, who were designated to also serve meals, did not have aprons to wear during food service tasks.

The following item was in need of repair:

* Two ceiling tiles above the three compartment sink were damaged.

b. During an interview on 06/20/23, Staff 2 (Human Resources Manager) provided copies of food handler certification cards for kitchen staff. A review of the records showed Staff 5 (Dietary Server) did not have a current food handler's card. Staff 2 acknowledged the findings.

At 11:40 am, the above areas were discussed with Staff 4 (Executive Director) and Staff 3 (Administrator in Training). They acknowledged the findings.

*Aprons have been provided to staff and are available for their use daily. Staff made aware that these are to be used when serving food to residents to reduce cross contamination.

*Garbage can with lid purchased for kitchen use in memory care.

* There is seran wrap and a sharpie available to staff in the kitchen to ensure that items are covered and dated prior to being put into the fridge or freezer. Staff has been coached that foods that are not dated or covered are to be thrown out immediately. Staff has also been coached on personal lunches not being stored in memory care fridge/freezer, personal food and lunches are to go in break room fridge/freezer. If personal food is found in the freezer, it will be moved to break room immediately. The Arbor Admin will audit this weekly.

* Oven and stove top has had a deep clean done by housekeeping crew and will be done weekly ongoing. Noc shift staff will do spot cleaning daily to maintain. Arbor Admin will audit this weekly.

Based on interview, observation and review of documentation, 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.

see C 240

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 plan of correction for C 240.

Based on observation, interview and record review, 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.

see C 240