The findings of the kitchen inspection, conducted 02/26/24, 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 revisit to the kitchen inspection of 02/26/24, conducted 04/29/24 though 05/02/24, 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 and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview, and record review, it was determined the facility failed to ensure food was prepared and 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, the Memory Care kitchenette, food storage, food preparation, and service on 02/26/24 revealed:

Spills, splatters, and debris were noted:

- The knobs, handles, sides and interior of the range;

- The interior of the microwave in the Memory Care kitchenette;

- Interior of drawers throughout the kitchen;

- The open shelving and shelving legs throughout the kitchen;

- Interior of reach in refrigerators;

- Shelving and floor of walk in freezer and refrigerator;

- Fan cages in the walk in refrigerator;

- Hand washing sinks and surrounding walls;

- Knife storage box and bin;

- Interior and exterior of the ice machine;

- Stand mixer and bin of mixer attachments;

- Open carts used for food delivery;

- Hot cart used for food delivery;

- Floor drains;

- Floor throughout the kitchen, and

- Sides of garbage cans.

* The garbage cans lacked lids.

* There was grease and dust build up on the range hood.

* The tray line cutting board and color coded cutting boards were deeply scored and stained.

* There was a dented canned food item in the dry storage area.

* Staff 3 (Cook) explained the facility used auto dispense Quaternary solution for the sanitizer buckets. There was no documented evidence it was monitored to ensure the correct solution. The sanitizer bucket was tested and found to be at the correct part per million. Staff 3 said the bucket was changed every four hours. Dry towels were noted on the tray line cutting boards and observed to be used by staff to wipe hands during meal preparation and service.

* The high temperature dish machine was not monitored to ensure correct temperatures were reached to sanitize dishes.

* Dish racks were stored directly on the floor.

* Items were stored on the floor in the walk in freezer.

* Utensils were left in prepared foods stored in the refrigerators.

* Multiple prepared food items in the walk in, deli, and reach in refrigerators were not covered, dated, or labeled.

* Raw eggs were stored above ready to eat foods in the reach in refrigerator.

* Multiple packaged food items in all refrigerators were not dated when opened.

* Staff preparing breakfast were observed to not change gloves between tasks.

* There was no evidence the temperature of the reach in refrigerator in the Memory Care kitchenette was monitored.

The areas in need of cleaning, food storage guidelines, and hand hygiene were reviewed with Staff 1 (Executive Director) and Staff 2 (Executive Chef) on 02/26/24. They acknowledged the findings.

C240:  Daily cleaning logs are kept by staff in Memory Care and kitchen is cleaned (documented) by all (3) shifts.  Spot checks are completed by Dietary Manager, Memory Care Administrstor, and Executive Director.  An in-service meeting was held in March with all memory care team members (to ensure all staff members were in attendance) with the Executive Chef outlining cleaning in all areas (microwave, refridg, shelving, etc.)

Fan cages were cleaned the day of the actual inspection are are spot checked routinely and randomly by Maint. Dept and Executive Director.  

Hand washing sinks, interior and exterior of ice mechines cleaned and surrounding walls are cleaned routinely.  Also included in cleaning are the stand mixer and corresponding attachements

Kitchen staff along with several management team members are involved in the in-service training to ensure proper cleaning.

All areas of kitchen our oulined in the in-service training.  

Garbage can lids were ordered immidiately following survey and are in place now.

Range hood was cleaned immidiately and is spot checked weekly by Executive Director and Memory Care Administrator.  This also applies to all areas oulined under C 240.

Dented cans are disposed of or returned to food deliver service; food is inspected by Executive Chef or someone designated in their place upon delivery.

Executive Dir and Maintenance Dir, along with Exec. Chef will be meeting with service that provides solution to sanitizer (buckets).  This will be completed prior to date of compliance.

High Temp(s) dish machine is monitored and we have added a second thermostat per suggestion of compliance inspector.  An additional thermostat is added to refrdg. system(s).  

All areas outlined under 240 are are addressed in in-service cleaning with dieatry team; this includes but is not limited to:

dish racks (not to be placed on floor).

Items are no longer stored on the floor, this has been addressed on the in-service process.

Staff preparing all food are now wearing gloves, hair nets.

Mempry Care kitchenette is being monitored by Executive Dir, Memory Care Administrator, and Maint. Dir (who also supervises housekkeping teeam).  The housekeepoing team does do a daily wipe/down deep cleaning of Memory Care kitchenette.  

NOC shift care team is now responsible in both the Memory Care as well as the Assisted Living dining area to vaccuum all dining area floors.

Based on observation, interview, and record review, it was determined the facility failed to ensure food was prepared and 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:

Observations of the main kitchen, the Memory Care kitchenette, food storage, food preparation, dish washing, and service on 04/29/24 through 05/02/24 revealed:

The high temperature dish machine was not consistently monitored to ensure correct temperatures were reached to sanitize dishes. Temperatures documented were below 180 degrees Fahrenheit (F).

The high temperature dish machine was not reaching the required temperate during the rinse cycle. The rinse temperature gauge was not operating.

Staff demonstrated they were testing the temperature by colleting water during the cycle and measuring the water temperature when the rinse cycle was completed. This method was attempted on 04/30/24 and the water was not reaching 180 degrees F.

The need to ensure dishes were sanitized and equipment was maintained and monitored was reviewed with Staff 1 (Executive Director), Staff 4 (Dietary Manager), and Staff 5 (Environmental Services Director) on 05/01/24 and 05/02/24. They acknowledged the findings.

C240: Facility acknowledges that high temperature of rinse cycle on dishwasher failing to hit required minimum temperature of 180 degrees.  Gauges on the dishwasher are not functioning properly.  Diamond Refrigeration has already been contacted and come to the facility. They inspected on 5/2/24 and are currently preparing a work order to replace these gauges for the facility.  As we are familiar with their work, facility will proceed with work with this vendor. Estimated job to be completed well within May, 2024 (per vendor).  This will resolve high rinse temperature issue.  In the meantime, facility is utilizing another vendor, Ecolab, to add chemical to meet the minimum low-temperature requirement of 140 degrees.

Temperatures are monitored daily by Staff 4 (Dietary Manager) and Staff 5 (Environmental Manager) to ensure minimum temperatures are being met.

Based on interview, observation, 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 C 240.

see 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.

The Memory Care Community will comply with all items mentioned relating to their portion falling under tag 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 240

C455:  Facility will meet plan of correction by 6/16/24 and, therefore, meet all areas of compliance as noted in survey of 5/2/24.