The findings of the kitchen inspection, conducted 07/25/23, 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 revisit to the kitchen inspection of 07/25/23, conducted 10/11/23, 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 07/25/23, conducted 12/20/23, 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 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:

Observations of the main kitchen and memory care kitchenette were reviewed on 07-25-23 from 10:45 am through 2:50 pm and the following was observed:

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:

* Waffle maker;

* Reach in coolers and freezers;

* Walk in freezer floor;

* Plastic and metal racks in walk in cooler;

* Cooling fans and cages in walk in and ceiling with dust accumulation;

* Bottom two plastic shelves storing potatoes;

* Interior of ice machine;

* Interior and exterior of microwave;

* Industrial can opener; and

* Box fan and oscillating fan blades and cages.

b. The following areas were in need of repair:

* Metal racks in reach in coolers with rust and peeling paint; and

* Caulking behind hand washing sink with black mold like substance.

c. Commercial observed slicer not covered when not in use. Staff 3 (Executive Chef) verified slicer did not have a cover.

d. Multiple cutting boards and cutting surfaces were found heavily stained and scored.

e. Prepared salads were observed stored in coolers without covers and open to potential contamination. A tray of salads was sitting on top of tray cart for memory care delivery. Two trays of dessert items found in walk in freezer uncovered. Staff 2 (Food and Beverage Director) stated everything prepared should be covered before placing in coolers to protect from potential contamination.

f. Multiple food packages were found open in dry storage. Pipes and vents in dry storage had heavy dust accumulation posing potential contamination risk to open packages.

g. Multiple bulk food bins or packages were found with scoops stored inside/on food product exposing it to potential contamination.

h. Multiple dishwashing racks were observed stored on the floor.

i. Multiple kitchen staff were observed during tray line service to use single service gloves incorrectly. Multiple ready to eat items were handled with gloves that had been used for other tasks including touching handles of ovens, fryer baskets, and cooler handles. Gloves were not removed after touching face, hair, glasses or clothing then observed to make sandwiches and/or handle fresh basil, garlic bread and shredded parmesan.

j. The memory care kitchenette and meal service was observed for lunch and the following was found:

* Fruit cups stored in counter cooler uncovered;

* Container of deli sandwiches and multiple prepared cinnamon butter containers were observed stored in reach in refrigerator not labeled or dated as required;

* Clean dishes were put away in cupboards wet with visible moisture accumulation in and under dishes (cups and mugs);

* Black matter found in grout behind sink;

* Trash can did not have a lid for when not in use;

* Container of flour and coffee were observed with scoop stored with food product;

* Light fixture and vents with large dust accumulation;

* Salads stored uncovered on counter from 11:20 am until meal service at 12:20 pm;

* Meal trays delivered to memory care from ALF kitchen at 11:20 am and were not served until 12:20 pm. Memory care staff did not check the temperature of food items prior to service to resident to ensure they were at appropriate and safe temperatures after sitting for an hour. Memory care staff indicated they did not have a thermometer and had not ever checked the temperature of food. Memory care staff were not aware of the temperature requirements needed to safely reheat food items.

* Memory care staff were observed to potentially contaminate hands doing multiple tasks and touching multiple potentially contaminated items and did not wash their hands as required.

At approximately 2:00 pm, the surveyor reviewed above areas with Staff 2 (Food and Beverage Director) and Staff 3 (Executive Chef), who acknowledged the identified areas. At 2:45 pm, the areas were reviewed with Staff 1 (Executive Director) and he acknowledged the concerns.

C240 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:

Waffle maker was cleaned and ordered replacement. Walk in freezer floor, Plastic and Metal racks in walk in cooler immediately cleaned. Cooling fans and cages in walk in and ceiling with dust accumulation have been pressure cleaned and replaced. Bottom two plastic shelves have been removed and replaced with new shelves. Interior of ice machine, interior and exterior of microwave, Industrial can opener and box fan and oscillating fan blades and cages have been removed/or sanitized.

All issues addressed in C240A have been added to a daily cleaning check list, will be maintained daily by chefs/dishwasher and evaluated on a daily schedule. Dining service Director is responsible to see that the corrections are completed and monitored.

C240B:Metal racks in reach in coolers with rust and peeling paint; and caulking behind hand washing sink with black mold like substance:

Metal racks have been removed and will not be replaced. Removing caulk, cleaning of areas and replacement of caulk will be completed.

All issues addressed in C240B have been eliminated through removal of product and maintance on a weekly check list will be maintained by Dining Service Director.

C240C: Commercial slicer was not covered:

Immediately placed plastic cover over product and Inserviced kitchen staff has been completed.

C240D: Multiple cutting boards stained have been removed and replaced.

Cutting surfaces that have been stained have been cleaned and stains removed. Dining Service Director and Chef will inspect cutting boards and cuttinging surface areas monthly.

C240E: Prepared salads and multiple food items were observed without coverings in the coolers as well as out for delivery:

Staff meeting included training on food contamination and staff have been instructed and retrained to keep all food covered while transporing or storing. Dining Service Director/ Chef will monitor.

C240F: Multiple food packages were found in dry storage open.

Pipes and vents in dry storage had heavy dust accumulation posing potential contamination risk to open packages.

All opened items were removed, staff advised of keeping items sealed at all times when storing, continued monitoring monthly by the Maintance Director to ensure no dust accumulation. Maintance Director will maintain monthly oversite.

C240G: Multiple bulk food bins or packages were found with scoops stored inside/on food product exposing it to potential contamination.

Staff inserviced and scoop will remain out of containers and hung on the hook.

C240H: Multiple dishwashing racks were observed stored on the floor.

Staff Inserviced to keep racks on shelf or dolly.

Chef will monitor daily that racks are stored correctly.

C240I: Multiple kitchen staff observed during tray line service to be using single service gloves incorrectly.

Staff observed to be handeling ready to eat items with gloves on and then touching possible contaminated surfaces.

All kitchen staff were inserviced on proper glove use in Accordance with Oregon Health Service Food Sanitation Rules OARs 333-150-000. Continued monitoring and

training will be on a routine schedule and oversite by Chef and Dining Service Director.

C240J: The memory care kitchenette and meal service was observed for lunch and the following was found:

*Fruit cups stored in counter cooler uncovered;

Servers will ensure all open containers will be covered with plastic wrap. Staff consulted and reminded that they must have covers on all open stored containers. Head Chef and DSD will audit coolers weekly.

*Container of deli sandwiches and multiple prepared cinnamon butter containers were observed stored in reach in refrigerator not labeled or dated as required.

Removed all unlabeled containers and disposed of items.

Lead server will inspect the refrigerator twice weekly and dispose of expired food per Food Health Safety Standards.

* Clean dishes were put away in cupboards wet with visible moisture accumulation in and under dishes (cups and mugs);

Kitchen staff will ensure that the dishes are returned clean and dry before memory care staff place back in cupboards. Staff have been counseled to not put dishes away wet.

* Black matter found in grout behind sink;

Resolved- Grout cleaned, placed task on monthly quality check. Maintanace Director will be responsible for reviewing monthly task is completed.

* Trash can did not have a lid for when not in use;

Resolved-Garbage can lids will remain on garbage can at all times. MCC and Lead Med Tech will ensure compliance daily.

* Container of flour and coffee were observed with scoop stored with food product;

Scoop has been ordered and staff will keep scoop on the hook after using products. Dining service team and Memory care coordinator will inspect for compliance weekly.

* Light fixture and vents with large dust accumulation;

Resolved- Maintance team have added to the check list of monthly tasks to maintain cleanliness. Memory Care Coordinator is responsible for the oversight.

* Salads stored uncovered on counter from 11:20 am until meal service at 12:20 pm; Kitchen staff will provide a cover that will remain on each open food item. DSD will ensure that the kitchen and all staff are advised to keep items covered.

* Meal trays delivered to memory care from ALF kitchen at 11:20 am and were not served until 12:20 pm. Memory care staff did not check the temperature of food items prior to service to resident to ensure they were at appropriate and safe temperatures after sitting for an hour. Memory care staff indicated they did not have a thermometer and had not ever checked the temperature of food. Memory care staff were not aware of the temperature requirements needed to safely reheat food items.

Staff have been given a thermometer for testing food prior to giving to ensure proper temps. Staff immediately in serviced on proper food temps. DSD will continue to monitor temp logs for consistency and safety.

* Memory care staff were observed to potentially contaminate hands doing multiple tasks and touching multiple potentially contaminated items and did not wash their hands as required.

Staff inserviced on proper don and doff of gloves for food safety. Proper glove usage will be monitored by Memory Care Coordinator. Monthly reminders on proper glove wear will be conducted by Memory Care Coordinator.

Z 142 SS=F OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Staff will read survey for ALF as well as Footsteps to remain in comliance with OAR's for Assisted Living and RCF.

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:

Observations of the facility kitchen, reviewed on 10/11/23 from 11:15 am through 1:00 pm, revealed 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:

* Walk in freezer floor; and

* Cooling fans and cages in walk in and ceiling with dust accumulation.

b. The following areas were in need of repair:

* Metal racks in reach in coolers with rust and peeling paint.

c. Multiple kitchen staff observed during tray line service to use single service gloves incorrectly. Multiple occasions ready to eat items were handled with gloves that had been used for other tasks including touching handles of ovens, fryer baskets, and cooler handles. Staff were also observed to handle raw meat products with gloves and did not wash hands before donning clean cloves. Staff were observed to handle ready to eat food products with bare hands.

d. Staff were observed to prepare multiple beef burgers and a veggie patty on the grill and did not check temperature prior to serving to residents. Staff 3 (Executive Chef) acknowledged the expectation for line cooks to check the temperature of potentially hazardous food items prior to service to ensure they have been cooked to the appropriate temperature as required.

e. Memory care kitchenette and lunch service was observed at 11:30 am - 12:00 pm. Staff were observed to handle ready to eat food items with potentially contaminated single service gloves and/or bare hands.

At approximately 1:00 pm, the surveyor reviewed above areas with Staff 2 (Food and Beverage Director) and Staff 3 (Executive Chef), who acknowledged the identified areas. At 12:45 pm, the areas were reviewed with Staff 1 (Administrator) and s/he acknowledged the concerns.

Tag C 240 with alphabetized points and plans for correction:

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:

oWalk in freezer floor; THE KITCHEN TEAM SCHEDULED A DEEP CLEAN FOR TWO DATES IN ORDER TO RESET THE FREEZER FLOOR TO CLEANLINESS STANDARDS; 10/25 AND 10/27. THEY WORKED WITH OUR CLEANING COMPANY TO OBTAIN THE PROPER CHEMICALS AND WILL DECK-BRUSH THE ENTIRE FLOOR, FOLLOWED BY MOPPING, UNTIL THE FLOOR IS CLEAN. THIS TASK HAS BEEN ADDED TO THE DISHWASHER LIST OF WEEKLY DUTIES TO ENSURE THAT IT IS DONE CONSISTENTLY.

oCooling fans and cages in walk-in and ceiling with dust accumulation; ON 10/11/23, AS SOON AS THE INSPECTOR LEFT THE BUILDING, THE MAINTENANCE TEAM PERFORMED THE NECESSARY DUSTING. THIS HAS BEEN ADDED TO A RECURRING MONTHLY TASK LIST FOR OUR MAINTENANCE/HOUSEKEEPING TEAM.

b)The following areas were in need of repair:

oMetal racks in reach-in coolers with rust and peeling paint; OUR TEAM HAS DETERMINED THAT THE METAL RACK WAS NOT SALVAGABLE AND HAVE ORDERED A REPLACEMENT RACK.

c)Multiple kitchen staff observed during tray line service to use single service gloves incorrectly. IN HOUSE TRAINING PERFORMED ON 10/12/2023 AND SCHEDULED FOR ONGOING REVIEW. Multiple occasions ready-to-eat items were handled with gloves that had been used for other tasks including touching handles of ovens, fryer baskets, and cooler handles. Staff were also observed to handle raw meat products with gloves and did not wash hands before donning clean gloves. Staff were observed to handle ready to eat food products with bare hands. TONGS WERE PROVIDED ON 10/12/2023 FOR THE RAW MEAT HANDLING TO MINIMIZE THE NEED FOR GLOVE CHANGES. IN HOUSE TRAINING ON 10/12/2023 ALSO COVERED NOT USING BARE HANDS.

d)Staff were observed to prepare multiple beef burgers and a veggie patty on the grill and did not check temperature prior to serving to residents. Executive Chef acknowledged the expectation for line cooks to check the temperature of potentially hazardous food items prior to service to ensure they have been cooked to the appropriate temperature as required. TRAINING ON 10/12/2023 COVERED THE EXPECTATION FOR ALL COOKS TO TEMP ALL MEATS TO ENSURE PROPER TEMPERATURE.

e)Memory Care kitchenette and lunch service was observed at 11:30 am - 12:00 pm. Staff were observed to handle ready to eat food items with potentially contaminated single service gloves and/or bare hands. TRAINING SCHEDULED FOR USAGE OF GLOVES ON READY TO EAT ITEMS

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 C 240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval:

(2) The facility "Footsteps" shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident ' s safety or welfare, as described in OAR 411-054-0028(4).

(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.

(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.

(b) Subsection (a) will not go into effect until July 1, 2022.

(c) Facilities not in compliance with these rules must submit, within ten days of

receipt of the inspection report, a plan of correction that satisfies the Department.

(d) The Department may impose sanctions for failure to comply with these rules.

(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: 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 C 240.

Based on observation, record review and interview, 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 observation, record review and interview, 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.

{Z 142} SS=F OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, record review and interview, 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.

Staff will read survey for ALF as well as Footsteps to remain in compliance with OAR'S for Assisted Living and Footsteps.