The findings of the kitchen inspection, conducted 08/03/23, 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 and OARs 411 Division 57 for Memory Care Communities.

The findings of the first revisit to the kitchen inspection of 08/03/23, conducted 10/27/23, 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 revisit to the kitchen inspection of 08/03/23, conducted 12/07/23, 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 third revisit to the kitchen inspection of 8/03/23, conducted 02/15/24, 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 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 333-150-000. Findings include, but are not limited to:

On 08/03/23 the first floor main kitchen, and second and third floor kitchenettes were inspected. 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, around or underneath the following:

* Floor throughout the kitchen including the dry storage area;

* Stainless steel upper and lower shelves throughout the kitchen;

* Caulking above the one compartment sink backsplash;

* Warewasher;

* Toaster;

* Hobart mixer;

* Industrial can opener;

* Stainless steel cabinets throughout the kitchen;

* Entryway doors and door frames, door to mop closet, and door to dry storage area;

* Ceiling vents throughout the kitchen; and

* Mop sink.

b. The following equipment was in need of repair:

* Entryway door was missing a transition strip;

* Mop closet was missing the right door;

* Right corner flashing to the mop closet was off, it was located leaning against the wall in the storage closet; and

* Exterior wall and door frame to the dry storage, interior and exterior doors, door frames and walls in the chemical storage closet, and wall above the three compartment sink had gouges and holes and were uncleanable.

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 (ED) and Staff 1 (Kitchen Manager) on 08/03/23. They acknowledged the findings.

C240:

1.All areas of kitchen identified have been cleaned.

All areas identified in need of maintenance have been fixed.

2.Audits to be conducted to maintain kitchen cleanliness.

3.Kitchen manager do conduct review of daily check list of cleaning schedule.

Administrator or designee to conduct weekly rounds to assure cleanliness.

Maintenance to conduct weekly rounds in kitchen to assure ongoing compliance of

any needed maintenance repairs.

4.Weekly rounds to be initiated, documentation of these rounds to be audited monthly by

Administrator or designee.

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 333-150-000. This is a repeat citation. Findings include, but are not limited to:

On 10/27/23 at 9:20 am, the first floor main kitchen was inspected and was observed to need cleaning and repair in the following areas:

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

* Flooring throughout the kitchen and dry storage area;

* Walls throughout the kitchen and dry storage area;

* Stainless steel shelving throughout the kitchen;

* Stainless steel cabinets throughout the kitchen;

* Legs of stainless steel shelving throughout the kitchen;

* Warewasher;

* Toaster;

* Blenders and Robot Coupe; and

* Ceiling vent near the warewasher.

b. The following equipment was in need of repair:

* Baseboard between prep area and refrigerators; and

* Shelving unit to the left of the stove.

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 (ED) on 10/27/23. She acknowledged the findings.

1.All areas of kitchen identified have been cleaned.

All areas identified in need of maintenance have been fixed.

2.Audits to be conducted to maintain kitchen cleanliness.

3.Administrator or designee to conduct review of daily check list of cleaning schedule.

Administrator or designee to conduct weekly audits to assure cleanliness.

Maintenance to conduct weekly audits in kitchen to assure ongoing compliance of

any needed maintenance repairs.

4.Weekly audits to be initiated, documentation of these rounds to be audited monthly by

Administrator or designee.

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 333-150-000. This is a repeat citation. Findings include, but are not limited to:

On 12/07/23 at 3:00 pm, the first floor main kitchen was inspected and was observed to need cleaning and repair in the following areas:

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

* Flooring throughout the kitchen and dry storage area;

* Walls throughout the kitchen and dry storage area;

* Stainless steel shelving throughout the kitchen;

* Stainless steel cabinets throughout the kitchen;

* Legs of stainless steel shelving throughout the kitchen;

* Warewasher;

* Toaster;

* Ceiling vent near the warewasher.

b. The following equipment was in need of repair:

* Baseboard between prep area and refrigerators.

c. An open container of empty beverage cans was observed under the sink behind the grill.

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 (ED) on 12/07/23. She acknowledged the findings.

C240:

1.All areas of kitchen identified have been cleaned.

All areas identified in need of maintenance have been fixed.

2.Audits to be conducted to maintain kitchen cleanliness.

3.Administrator or designee to conduct review of daily check list of cleaning schedule.

Administrator or designee to conduct weekly audits to assure cleanliness.

Maintenance to conduct weekly audits in kitchen to assure ongoing compliance of

any needed maintenance repairs.

4.Weekly audits to be initiated, documentation of these rounds to be audited monthly by

Administrator or designee.

Based on interview and record review, it was determined the facility failed to ensure documentation of current food handlers certificates for 2 of 3 staff (#s 3 and 4) whose duties included preparing food. Findings include, but are not limited to:

The kitchen inspection including a review of training records was completed on 08/03/23.

Staff 3 and 4 (Cooks), hired on 08/08/20 and 02/28/18 respectively, lacked documented evidence of current food handlers certificates.

The need to ensure staff, whose duties included preparing food, had current food handlers certificates was discussed with Staff 1 (ED) and Staff 2 (Kitchen Manager) on 08/03/23. They acknowledged the findings.

C370:

1.BOM will identify and inform staff of pending expirations of certifications and monitor for

completion for compliance.

2.Audits to be conducted by BOM bi-weekly

3.Administrator or designee to conduct monthly review of audit.

4.Documentation of audits to be completed monthly.

Based on interview and observation, 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 C 240

Based on interview and observation, 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.

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 C240 and C370.

Z142:

Refer to C240 and C370

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.

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240.

Refer to C240