OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement program that evaluated services, resident outcomes and resident satisfaction. Findings included, but are not limited to: During the annual kitchen survey, conducted 12/24/24, quality improvement oversight was found to be inadequate to ensure the facility's dining services were maintained in a safe and sanitary condition, following Oregon food code practices and menus as outlined in rule.

Weekly audits to be completed by administrator. Documentation of this will be kept in a binder in the kitchen. New task sheets for cleaning tasks presented during all staff meeting. Documentation of this will be kept in a binder in the kitchen. DSC will complete cleaning audits 5 days a week. Menu chat will held twice monthly where concerns will be addressed. Comment cards and grievance log will be reviewed five times weekly by ED and followed up on in a timely manner.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: 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 facility kitchen was completed on 12/27/24 from 10:30 am through 2:30 pm and the following was identified: 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: * Floors throughout kitchen; * Floors in the dining room; * Walk in cooler floors under metal shelving and in thresholds; * Walls throughout kitchen behind prep areas; * Open shelving throughout kitchen; * Interior and exterior of microwave; * Interior and exterior of convection ovens; * Industrial can opener and housing; * Industrial mixer; * Door thresholds with food debris/splatter; * Interiors and exteriors of stainless steal drawers; * Go racks stored in walk in; * Metal racks in walk in cooler and freezer; * Outsides and handles of trash cans; * Small appliances (blender/robot coupe); * Windowsills and screens; * Vents and light fixtures; * White food bin exteriors; * Utility carts; * Dish washing rack dolly/cart; * Interior and exterior of food transportation carts; * Clean area of dish washing station; * Floors and walls in dish washing area; * Kitchen drains; and * Water cooler in dining room; b. The following areas were in need of repair: * Multiple ceramic tiles in threshold of walk in cooler and freezer with cracks; * Multiple areas in dining room walls with missing, chipped or scrapped paint; * The walk in freezer had a large accumulation of ice that was on cardboard boxes and had dripped/froze potentially contaminating food product in the cardboard boxes below the drip/freeze. c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. d. Multiple potentially hazardous foods were found past 7 days from the original preparation date. A large container of chicken salad was dated 11/16/24 and was observed to have visible mold growth on the food product. Another container of tuna salad was dated 11/22/24 and was observed with visible signs of food decay/rot. A container of prepared sandwiches was noted dated 12/14/24, 14 days from preparation date. e. Multiple food items found in walk in cooler noted without proper labels and/or dates when opened or prepared as required. Multiple items were found open and/or not covered/sealed appropriately to protect from potential contamination. f. Multiple kitchen staff were observed preparing food and/or handling clean dishes without appropriate facial hair restraints as required. g. A kitchen employee was observed to have on plastic gloves underneath visibly heavily soiled rubber gloves washing dishes. The staff removed the soiled gloves and handled clean dishes with the visible wet plastic gloves on underneath the soiled rubber gloves. No hand hygiene step was observed between dirty and clean tasks as required. h. A container of hot sauce, a visible dirty metal baking supply, and a to-go coffee cup was observed on the clean side of the dish machine potentially contaminating the clean area of the dish area. The coffee cup was an employee drink and did not contain the appropriate straw or handle as required. i. The kitchen had four red surface sanitizing buckets. These buckets were tested for appropriate surface sanitizing levels. The facility was asked for test strip and a quat 10 strip provided. None of the four buckets registered any concentration of sanitizing solution. Staff 2 (Dining Services Coordinator) was asked to make a fresh bucket and test the solution. The chemical that came from the dispenser did not register any quat sanitation which is what staff 2 thought was the sanitizing chemical. When asked how frequent the buckets were changed staff 2 responded every 3-4 hrs not the every 2 hrs or as needed per rule. Facility indicated they would contact their Eco lab representative to check the dispenser as soon as possible. j. The snack fridge on the unit did not contain a thermometer to ensure food was stored at the appropriate cold food storage temperature. k. A week’s worth of menus was requested at the start of survey, Staff 2 indicated the facility did not currently have 7 days of menus in advance as required. Staff 2 stated they were working on developing the menus as required but was short staffed and had not been able to complete it. Staff 2 indicated they had to change the menu to use up food supply. Staff 2 was asked if residents were notified in advance when menu items changed. Staff 2 stated they did try to let them know if and when they could. Staff 1 (Executive Director) was interviewed and acknowledged the facility currently did not have a system for communicating menu changes with residents per guidelines. Staff 2 (Dining Service Coordinator) toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 2:00 pm, surveyor reviewed above areas with Staff 1 (Executive Director), who acknowledged the findings.

Week at a glance menu, daily menus and weekly snack menu posted. All menus are signed off on by a registered dietitians. Snacks are accessible and available to residents 24 hours a day. Fresh fruit is available in the front lobby. Menu chat held twice monthly. During this meeting resident involvement in menu planning is highly encouraged. All substitutions will posted a accessible to residents prior to the meals via chalk board located outside the dining room in AL and on menu board in MC. Eco lab providing test strips for sanitation buckets that will be changed every two hours. Staff will be trained on this process during all staff meeting. Eco lab representative has been contacted to check the sanitizing chemical dispenser. Kitchen staff will be presented with and trained on updated daily cleaning tasks. Heavily used kitchen equipment/small appliances such as microwave, can opener and mixer have been added to daily and as needed cleaning tasks. Kitchen vents and pipes have been cleaned and added to TELS for scheduled twice a month cleaning. Kitchen window screens have been replaced. Kitchen staff have been trained on use of scoops for food bins. Sign with reminder of this direction can be found located near the bins. Dish washing rack have been cleaned and sanitized. This will be done on an ongoing basis. Floors and walls in dish pit have been cleaned and sanitized. All non-cleanable surfaces will be repaired. This area has also been added to routine cleaning schedule. Community has been contacted 3rd party company to have tiles in walk-in cooler/freezer repaired. This has been completed. Uncleanable surfaces on wall in dining area will be repaired and repainted. Walk-in freezer has been de-iced and added to weekly and as needed task list. Proper food storage and labeling will retrained and is being checked daily with task sheet and overseen by kitchen manager. Beard nets are now available to staff with facial hair and being used as required. Proper use of gloves/hand hygiene has been trained including no double gloving. Personal drinks will have lid/straw as required in kitchen area. Snack fridge now has a temp log and thermometer to ensure proper temp holding. Infection prevention policy binder is available to all kitchen staff. Crandall Corp. Dietitians services have been obtained and to ensure continued compliance. weekly audits to be completed by Administrator. New task sheets for cleaning tasks presented during all staff meeting. DSC will complete cleaning audits 5 days a week. Menu chat will held once monthly where concerns will be addressed. Comment cards and grievance log will be reviewed five times weekly by ED and followed up on in a timely manner.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: