The findings of the kitchen inspection, conducted 01/25/24, 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 01/25/24, conducted 10/24/24, 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 revisit to the kitchen inspection of 01/25/24, conducted 02/20/25, 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.   

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third revisit to the kitchen inspection of 01/25/24, conducted 04/15/25, 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.

Tag numbers beginning with the letter 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.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day  

The findings of the fourth re-visit to the kitchen inspection of 01/25/24, conducted 06/06/25, 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 observations and staff interviews, it was determined the facility administration failed to provide necessary oversight of the food service program to achieve and maintain compliance with food sanitation rules. Findings include, but are not limited to:

On 04/15/25 at 10:15 am, a revisit kitchen survey was conducted which found multiple areas that remained out of compliance. This was the third failed revisit for the kitchen survey.

At 11:15 am, Staff 1 (Administrator) and Staff 2 (Dietary Manager) acknowledged the need for enhanced oversight of the kitchens and food service program.

*Based on observations and staff interviews, it was determined the facility administration failed to provide necessary oversight of the food service program to achieve and maintain compliance with food sanitation rules. Findings include, but are not limited to: On 04/15/25 at 10:15 am, a revisit kitchen survey was conducted which found multiple areas that remained out of compliance. This was the third failed revisit for the kitchen survey.

oNew labeling and cleaning processes put in place, several trainings provided on new processes. Daily oversight from Executive Director and Dietary Manager for compliance.

Monthly RD oversight to ensure compliance for at minimum 90 days.  

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 house 2 and 3 kitchen areas were reviewed on 1/25/24 from 11:30 am through 2:30 pm and found the following:

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

* Inside and outside of reach in coolers and freezers;

* Fans blades, cages and screen of open window in house 1;

* Ceiling vents;

* Walls;

* Interior of microwaves;

* Interior of ovens;

* Industrial can opener housing;

* Underneath, between and behind equipment;

* Floor mats:

* Kitchen floors;

* Open shelving:

* Drawers and cabinets;

* Metal legs of tables/prep spaces;

* Interior and exterior of Rubbermaid drawers; and

* Drains under sinks.

b. The following areas were in need of repair:

* Small holes in walls throughout kitchens;

* Reach in refrigerator with large crack in drawer;

* Significant floor damage under sink in Kitchen 2:

* Multiple cupboard/cabinets/shelving with exposed porous wood;

* Window seal in house 1 kitchen with non smooth surface for cleaning;

* Countertops with visible damage and signs of ware in multiple areas;

* Dining room chairs with un-smooth surfaces with damage to outer layer of seating surfaces;

c. Multiple sauté pans were observed with visible damage of nonstick surface. Plastic cups, mugs, bowls were noted with pitting and glaze worn yielding un-smooth surfaces.  

d. Multiple plastic spatulas or other utensils were found in poor repair being heavily melted, scored, stained and/or with chunks missing. Multiple hot pads found with holes.

e.  Multiple items found in reach in refrigerators without date and/or resident identifiers. Multiple items found past the manufactures use by dates and or facility date marking for use within 7 days.  

f. Refrigerator in dining room of house 1 without thermometer to ensure items stored at appropriate temperatures.

g. Multiple dry good items stored unsecured and open to possible contamination. Other dry goods not dated when opened or manufactures use by date marked on item when removed from packaging. Some bulk food items found with scoops stored inside.

h. Care giving staff were not wearing aprons during meal service to create a clean barrier as a mechanism to prevent possible spread of infectious agents.

i. Dry good storage was noted to have stock stored on the floor. Staff 3 (Person in Charge/PIC) acknowledged s/he had not had a chance to put away stock yet.  Stock was delivered greater than 24 hrs prior. Upon interview it was determined PIC was also the primary maintenance worker for the facility. Staff 3 acknowledged that maintenance duties were taking away from time for cleaning and organizing food storage according to food code.

Staff 3 (Cook/PIC) toured kitchen areas with surveyor and acknowledged the findings. On 1/25/24 at approximately 1:15 pm, the surveyor reviewed the above areas with Staff 1 (Executive Director) and Staff 2 (Administrator) who acknowledged the identified areas.  

C240

1. All of the listed items have been or are in process of being deep cleaned:

* Inside and outside of reach in coolers and freezers;

* Fans blades, cages and screen of open window in house 1; * Ceiling vents;

* Walls;

* Interior of microwaves;

* Interior of ovens;

* Industrial can opener housing;

* Underneath, between and behind equipment;

* Floor mats:

* Kitchen floors;

* Open shelving:

* Drawers and cabinets;

* Metal legs of tables/prep spaces;

* Interior and exterior of Rubbermaid drawers; and

* Drains under sinks.

The following items have been or are being repaired:

* Small holes in walls throughout

kitchens;

* Reach in refrigerator with large crack in

drawer;

* Significant floor damage under sink in

Kitchen 2:

* Multiple cupboard/cabinets/shelving

with exposed porous wood;

* Window seal in house 1 kitchen with

non smooth surface for cleaning;

* Countertops with visible damage and

signs of ware in multiple areas;

* Dining room chairs with un-smooth

surfaces with damage to outer layer of

seating surfaces;

These items have been discarded and new ones purchased:

c. Multiple sauté pans

d. Multiple plastic spatulas, other utensils and hot pads in poor repair are ordered and being replaced.

e. All undated food and expired food has been discarded.

f. Thermometer purchased for the refrigerator in dining room of house 1

g. All dry good items will be stored in secure bins to ensure that they are free from contamination. All dry goods without open dates have been discarded. Expired dry goods have been discarded. The scoops are no longer stored in the bins.

h. Aprons have been ordered and caregiving staff have all been trained to wear aprons during meal service to create a

clean barrier as a mechanism to prevent

possible spread of infectious agents.

i. Additional staff have been hired to relieve PIC and to ensure that all food and supplies are put away immediately and are not on the floor according to food code.

2. All staff will go through training on proper cleaning, food storage, and infection prevention control.

All supplies will be closely monitored to ensure they are in good repair, and if not, will be discarded immediatley.

Kitchen cleaning task sheets are being implemented immediately.

3. Daily walk throughs and weekly monitoring of Kitchen Book w/temps, task sheets, etc.

4.The Dietary Manager and the Executive Direcor

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair, ensure menus were made available to all residents, and prepare and serve food 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:

Observations of the main facility kitchen and dining room in House 1, and Houses 2 and 3 kitchen and dining areas were made on 10/24/24 from 10:45 am through 2:45 pm. The following was identified:

a. The following areas were in need of repair:

* Multiple cupboard/cabinets/shelving had exposed porous wood;

* Windowsill in House 1 kitchen had non-smooth surface for cleaning;

* Countertops had visible damage and signs of wear in multiple areas;

* Dining room chairs had un-smooth surfaces with damage to outer layer of seating surfaces.

b.  Multiple items were found in refrigerators without facility date marking for use within 7 days.

c. Multiple items were found in refrigerators, identified by staff as for specific residents, without dates or resident identifiers.

d. Multiple items, identified by staff as belonging to staff members, were found on refrigerator shelves alongside food and beverages for residents. Some of the staff food and beverages had been partially consumed.

e. Refrigerator on the deck of House 2 did not have a thermometer to ensure items were stored at appropriate temperatures. Staff 3 (Dietary Supervisor) reported in an interview that the refrigerator had been donated to the facility two days previously and a thermometer was being delivered in the next 1-2 days with the next supply delivery. A thermometer from another refrigerator was placed in this refrigerator during survey and Staff 3 was instructed to recheck in a few hours to ensure the refrigerator was at the appropriate temperature. Upon inspection of the freezer on top of this refrigerator unit, the foods were found to not be frozen, including a 3 gallon drum of ice cream. Staff 3 was instructed to throw away all items in the freezer.

f. Care giving staff were not wearing aprons during meal service to create a clean barrier as a mechanism to prevent possible spread of infectious agents.

g. Staff members preparing food did not have hair restrained.

i. A menu for the current week was not available to residents in Houses 2 and 3. Multiple staff members reported the menu was typically posted on the bulletin board in the dining room, but they had not seen one for the current week. Staff 3 acknowledged the current week menu had not been made available to residents.

These findings were discussed with Staff 3 throughout the day and reviewed with Staff  2 (Executive Director) and Staff 3 at 2:30 pm.  They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident?1. All listed items have/are in the process of being repaired or replaced:

?Cabinets, cupboards and shelving with exposed porous wood, all Houses.

?Windowsill in House 1 non-smooth surface for cleaning.

?Countertops with visible damage and signs of wear all Houses.

?Dining room chairs with un-smooth surfaces and damage to the outer layer of seating surface all Houses.

?Will be replacing the refrigerator/freezer, non-working unit removed.

?Marking facility date, for use within 7 days.

?All resident food items will be dated with open/expiration date and resident identifier.  

?All staff food items will be placed in a designated refrigerator for staff with an open/expiration date and staff identifier.  

?Weekly menus will be posted in designated areas with alternative menu. Copy of weekly menu and alternative menu will be offered to each resident.

? Aprons readily available for all staff, prior to entering the kitchen area. Education with documentation of date, training and sign off.

?Hairnets readily available for all staff, prior to entering the kitchen area. Education with documentation of date, training and sign off.

2. All-Staff Meeting will be held to review Kitchen Binder: Cleaning schedule- ways to identify and report uncleanable surfaces, Food Safety/Handling: Proper labeling, wearing of hairnets, beard nets, and aprons. Monitoring will occur regularly.

3. We will monitor with daily spot checks and weekly audits.

4. The RCC, Dietary Manager, Executive Director and Regional Director will be responsible for monitoring.?????

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair, ensure menus were made available to all residents, and prepare and serve food 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:

Observations of the main facility kitchen and dining room in House 1, and Houses 2 and 3 kitchen and dining areas were made on 02/20/25 from 1:45 am through 3:45 pm. The following was identified:

a. The following areas were in need of repair:

* Multiple cupboard/cabinets/shelving had exposed porous wood.

* Reach in refrigerator on the patio of House 2 had cracks/chips in the plastic areas along with the refrigerator was rusted along the entire outer door and was not holding temperature at 41 degrees or below as required.

b. The following items were needing cleaning;

* Multiple drawers, cabinets, and cupboards in the kitchen area in House 3 had food spills, crumbs, dirt and debris.

* Reach in refrigerator in House 3 had visible accumulation of liquid spills, food debris and dirt under the pull out drawers.

* Reach in refrigerators on the patio of House 2 had dirt/food debris/dust build up/ black/grey debris around the edges of door frames and door seals.

c.  Multiple items were found in refrigerators without facility date marking for use within seven days. Multiple potentially hazardous food items were observed opened and did not contain open dates as required per rule.

c. Multiple items were found in refrigerators, identified by staff as for specific residents, without dates or resident identifiers. Reach in refrigerator in House 2 dining room contained a container of store/restaurant bought pancakes that had no identifiers, no date, and had an accumulation of visible mold growth on the food product.

d. A reach in refrigerator in House 1 kitchen had a carton of whole shell eggs stored directly above ready to eat foods with no barrier to prevent possible spill/drip contamination to the packages of the RTE food items below. House 2 reach in refrigerator on the patio had boxes of raw chicken stored directly next to boxes of bacon. Raw chicken boxes were overlapping bacon boxes and posed a potential for cross contamination of products that have different cook to temperatures.

e. Refrigerator on the deck of House 2 did not have a thermometer to ensure items were stored at appropriate temperatures. Two cases of heath shakes were stored in the refrigerator. The boxes were marked "Keep Frozen". The health shakes were all in liquid form. Surveyor used thermometer to test the temperature of the refrigerator and it was found at 44 degrees. Staff 2 (Dietary Supervisor) was not aware that the health shakes were required to be stored frozen and that the use by date on the cartons was in the frozen state. Staff 2 was also unaware that the shakes were to be used within 14 days of thawing. Staff 2 was able to confirm those cartons were on that weeks shipment and that they would be used within the next seven days. Surveyor checked the temperature of the health shakes and they were at 37 degrees and they were moved to an alternate location to ensure proper temperature control.

f. Residents did not have access to the current weeks menus in Houses 2 and 3. Staff 2 acknowledged there was no weekly menu posted in House 2 and the incorrect/previous weeks menu posted in House 3. Staff 3 verified the correct/current weeks menus were available in the house kitchens in a binder and posted the menus at that time.

Staff 2 toured the kitchen areas with the surveyor and acknowledged the identified areas. At 3:30 pm the findings were reviewed with Staff 1 (Administrator) who acknowledged the areas.

All listed items below are/have been replaced/repaired/purchased or moved:

* Cupboards/cobinets/shelving with exposed porpus wood. (being update with material that provides a cleanable surface)

* Refridgerator H2 (not same as freezer from initail visit) being replaced.

* Thermometer purchesed

* All eggs moved to bottom shelf

* Raw meats moved/seperated to prevent potential cross contamination while being stored.

Items listed below have been added to daily task sheets. To be monitored for compliance by dietary manager 3x weekly.

* Drawers, cabinates, cupboards cleaned/wiped out.

* Wipe out inside/ouside of refridgators (including under the drawers.

* Items found without date marking use in 7 days.

* Items found in refidgerator without dates and identifiers for staff or residents.

* Access to resident menues in Houses 2/3.

All items listed below reviewed with staff via ALL staff meeting 2/25/25:

*Importance of having a clean enviornorment, dating all items with experation date

* List of experation date durations posted in each kitchen.

*  

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair, and prepare and serve food 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:

Observations of the main facility kitchen and dining room in House 1, and Houses 2 and 3 kitchen and dining areas were made on 04/15/25 from 10:15 am through 11:30 am. The following was identified:

a. The following areas were in need of repair:

* Large hole/damage to wall behind the door in the kitchen of house 2

* Large area in ceiling above the reach in refrigerator with water damage, paint and ceiling peeling/cracking.

b. The following items were needing cleaning;

* Reach in refrigerators and/or freezers in house 1, house 2 and house 3

c.  Multiple items were found in refrigerators without facility date marking for use within seven days. Multiple potentially hazardous food items were observed opened and did not contain open dates as required per rule.

d. Multiple items were found in refrigerators, identified by staff as for specific residents, without dates or resident identifiers. Multiple food items were found past seven days or were observed without dates but with noticeable decomposition indicating they were well past seven days or not safe for consumption.

e. Refrigerator in house one thermometer was checked at 10:30 am and was found at 50 degrees Fahrenheit. Staff 2 indicated the facility had just been putting away stock about one hour before. Surveyor placed their thermometer in the refrigerator and when checked at 11:00 am both the facility thermometer and the surveyor's thermometer both read well above 41 degrees at 50 degrees and 51.5 degrees respectively. A food item was checked and the temperature was at 49.3 degrees. Facility logs were reviewed and no temperature was documented for that refrigerator for that morning. Staff 1 (Administrator) and Staff 2 (Dietary Manger) were instructed that any potentially hazardous non shelf stable food products stored in that refrigerator that were found above 41 degrees would need to be discarded. Staff 1 and Staff 2 voiced understanding.

f. Opened package of hard boiled eggs were not closed and were stored open to potential contamination. There was no date opened on the package. Multiple items were observed in reach in refrigerators that did not have a label of what the food product was and the product was not clearly identifiable.  

Staff 1 and 2 toured the kitchen areas with the surveyor and acknowledged the continued areas not in accordance with food sanitation rules that were identified.

(A) The following areas were in need of repair;

* Large hole/damage to wall behind the door in the kitchen of house 2

       oRepaired and new door stopper installed.

* Large area in ceiling above the reach in refrigerator with water damage, paint and ceiling peeling/cracking.

       o Area has been inspected, repaired and repainted.

(B)  The following items were needing cleaning;

* Reach in refrigerators and/or freezers in house 1, house 2 and house 3

       o Tasks ares part of cleaning task sheets and will be monitored for compliance by Excutive Director and/or Dietary Manager daily.

(C) Multiple items were found in refrigerators without facility date marking for use within seven days. Multiple potentially hazardous food items were observed opened and did not contain open dates as required per rule.

(D) Multiple items were found in refrigerators, identified by staff as for specific residents, without dates or resident identifiers. Multiple food items were found past seven days or were observed without dates but with noticeable decomposition indicating they were well past seven days or not safe for for residents.

        o New labeling process. Labels will be placed upon arrivel. Once item is pulled/opened, label will be filled out with identifier/date open/use by date. This process will address C, D and F . Dietary Manager and Excutive Director to check daily for proper labeling.                            o Training to be provided to all staff on new process.

(E) Refrigerator in house one thermometer was checked at 10:30 am and was found at 50 degrees Fahrenheit. Staff 2 indicated the facility had just been putting away stock about one hour before. Surveyor placed their thermometer in the refrigerator and when checked at 11:00 am both the facility thermometer and the surveyor's thermometer both read well above 41 degrees at 50 degrees and 51.5 degrees respectively. A food item was checked and the temperature was at 49.3 degrees. Facility logs were reviewed and no temperature was documented for that refrigerator for that morning. Staff 1 (Administrator) and Staff 2 (Dietary Manger) were instructed that any potentially hazardous non shelf stable food products stored in that refrigerator that were found above 41 degrees would need to be discarded. Staff 1 and Staff 2 voiced understanding.

             o All items were disposed of. Tempature monitoring was done for 48hrs before restalking to ensure tempature was maintaining. Once restocked no further issues have been noted.

(F) Open package of hard boiled eggs was not closed and were stored open to potential contamination. There was no date opened on the package. Multiple items were observed in reach in refrigerators that did not have a label of what the food product was and the product was not clearly identifiable.

            o New labeling process. Labels will be placed upon arrivel. Once item is pulled/opened, label will be filled out with identifier/date open/use by date. This process will address C, D and F . Dietary Manager and Excutive Director to check daily for proper labeling.       o Training to be provided to all staff on new process.

Monthly RD oversight to ensure compliance for at minimum 90 days.    

Based on interview and record review, it was determined the facility failed to ensure their relicensure 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 observations and interviews, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. 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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240.

Refer to 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 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.

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

Refer to C 240.

Refer to C240

Based on observations, interviews 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 C150, C240 and C455.

Refer to C 150 and C 240.