The findings of the kitchen inspection, conducted 05/13/24 through 05/14/24, 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 revisit to the kitchen inspection of 05/14/24, conducted 09/09/24, 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 05/14/24, conducted 02/05/25, 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, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

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 05/14/24, conducted on 06/17/25, 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, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The facility was found to be in substantial compliance.

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen and memory care kitchenette on 05/13/24 and 05/14/24 showed the following areas needed cleaning or repair.

Main Kitchen:

* Drips, splatters and/or debris were observed inside cupboards, under shelves, on top of dry goods, inside drawers, on the ceiling and on the walls throughout the kitchen and dry storage;

* A broken light cover was noted near the tray line, other light covers had debris and dead insects inside and missing covers were noted to the lights in the dry storage;

* Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of flooring around the center island were heavily discolored with a black/brown haze;

* Shelving in multiple refrigerators and/or freezer units had spills, debris, white accumulation with dangling pieces, rust and chipped/peeling shelf coating;

* Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board, bubbling paint;

* Chipped laminate was noted on counter edges of the center island, the back splash was pulling away from the wall along the back counter, the counter near the back corner was pulling apart at the seam;

* Debris and standing water were located in the drain under the sink as well as black stains along the interior walls and a strong sour odor;

* The ice machine had spills and debris on the lower vent slats, broken and missing slats were noted as well;

* Metal shelves throughout the kitchen had debris, drips and/or spills;

* Two cutting boards were worn with numerous grooves;

* Four large plastic pitchers were stained brown and had scrapes on the interior;

* Debris, spills and stains in cupboard drawers and on shelves in the dining room drink station;

* Scoop handles were extremely worn, scratched and gouged;

* Large amounts of debris were noted underneath the stove on an exposed shelf area. The ovens did not have a cover piece in place along the bottom as it impeded the opening and closing of the oven doors;

* Numerous open packages were noted in the dry storage area including cake mix, sugars, flour, biscuit mixes and breadcrumbs;

* Cobwebs, dust and dead insects were noted in the windowsill, the screen to the open window had a thick layer of dust and debris on it; and

* Food splatters/spills were noted on the underside of the small stand mixer.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Executive Director) and Staff 2 (Dietary Manager) on 05/14/24. The staff acknowledged the findings.

1.Additional training to be completed with Dining Services Manager and Dining staff on proper cleaning and storage protocols.

Administrator and Maintenance Director will work together to repair and/or replace building defects and other areas of the kitchen in need of repair.

Administrator will work with Dining Services Manager to replace worn equipment and appliances.

2. Administrator will oversee Dining Services in weekly Kitchen cleaning inspections. The Dining Services Manager will provide Administrator with an inventory of items needing to be replaced or repaired, monthly.

3. Weekly and Monthly

4. Administrator and/or Dining Services Manager

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen 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 on 09/09/24 showed the following areas needed cleaning or repair.

* Drips, splatters and/or debris were observed inside cupboards, under shelves, inside drawers, and on the walls throughout the kitchen and dry storage;

* A broken light cover was noted near the tray line, other light covers had debris and dead insects inside and missing covers were noted to the lights in the dry storage;

* Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of flooring around the center island were heavily discolored with a black/brown haze and multiple seams were cracked or pulling apart;

* Shelving in multiple refrigerators and/or freezer units had spills, debris, white accumulation with dangling pieces, rust and chipped/peeling shelf coating;

* Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and bubbling paint;

* Chipped laminate was noted on counter edges of the center island, the back splash was pulling away from the wall along the back counter, the counter near the back corner was pulling apart at the seam;

* An open box of paper tray liners was stored on the floor next to the stove, multiple pieces of food and other debris were noted on the clean papers and inside the box;

* The ice machine had spills and debris on the lower vent slats, broken and missing slats were noted as well;

* Cobwebs, dust and dead insects were noted in the windowsill, the screen to the open window had a thick layer of dust and debris on it and multiple chips with exposed particle board noted; and

* The ceiling vent near the kitchen entrance had thick accumulation of dark gray dust.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED), Staff 3 (Maintenance Director) and Staff 4 (Dietary Services Manager) on 09/09/24. The staff acknowledged the findings.

1.Continued training to be completed with Dining Services Manager and Dining staff on proper cleaning and storage protocols. The kitchen survey has been included in additional discussions and counceling on kitchen cleaning protocols. We have a new Dining Services Manager who is assisting in reaching these goals.

Administrator and Maintenance Director are continuing to work together to repair and/or replace building defects and other areas of the kitchen in need of repair. Plans for overcoming financial barriers in place.

Administrator has been and will continue working with Dining Services Manager to replace worn equipment and appliances.

2. Administrator will continue to oversee Dining Services in weekly Kitchen cleaning inspections. The Dining Services Manager will continue to provide Administrator with an inventory of items needing to be replaced or repaired, monthly.

3. Weekly and Monthly

4. Administrator and/or Dining Services Manager/Maintenance Director

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen 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 on 02/05/25 showed the following areas needed cleaning or repair:

* Missing covers were noted on the lights in the dry storage;

* Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment, and at the door edges;

* Shelving in the Victory refrigerator had rust and chipped/peeling shelf coating;

* Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and bubbling paint;

* The ice machine had broken and missing slats to the bottom vents;

* The interior walls under the sink by the range had black stains along the interior walls; and

* Doors and door frames throughout the kitchen had scuffs, scrapes, and/or gouges with bare wood exposed, rendering the surfaces uncleanable.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 3 (Maintenance Director), Staff 4 (Dietary Services Manager), and Staff 5 (Business Office Manager) on 02/05/25. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:

Refer to C240.

Please Refer to C240

Based on observation and interview, it was determined the facility failed to ensure their re-licensure 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.

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 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 C240.

Please Refer to C240

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.