The findings of the kitchen inspection, conducted DATE, 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.

Tag numbers beginning with 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.

The findings of the re-visit to the kitchen inspection of 06/26/24, conducted 08/15/24, 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 the Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 06/26/24, conducted 10/15/24, 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 third re-visit to the kitchen inspection of 06/26/24, conducted 12/11/24, 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, OARs 411 Division 57 for Memory Care Communities and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained and person in charge (PIC) had appropriate knowledge in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

* Observations of the facility kitchen, food storage areas, food preparation, and food service on 06/26/24 revealed splatters, spills, drips, dust and debris noted on:

- Interiors of drawers and cabinets;

- Drip pan/drawer under stoves;

- Sides of stove and between stoves and counters;

- Can opener;

- Plastic cabinet safety latches;

- Tops of cabinets where cooking equipment stored;

- Interior of microwave;

- Interior and exterior of reach in refrigerator;

- Spice shelves;

- Ceiling and floor in storage closet and:

- Walls behind prep spaces.

* The following items were in need of repair:

- Storage closet housing clean equipment and dishes had multiple holes near piping and or electrical conduit allowing potential access points for pests.

* Multiple items found stored in reach in fridge were not dated when opened and/or prepared or did not have a use by date as required. Several opened packages of food items were noted in the kitchen cupboards not securely closed and open to potential contamination. Several items did not contain open dates.

* Upon entry to kitchen a large bag of frozen chicken was defrosting in standing cool water. Staff 2 (cook/designated PIC) was not aware of correct defrosting methods and the need for continuous cold running water. Staff 2 placed under running water but after a few minutes turned off the water.

* Staff 2 was not sanitizing cooking equipment and utensils such as knives. Items that could not go thru dishwasher were only washed and rinsed and put away. Staff 2 did not know process of bleach water bucket sanitizing. Household sanitizing wipes were used to disinfect counter tops but there was no method available to sanitize cooking surfaces. Staff 2 was not sanitizing thermometers prior to or in between uses.

* Staff 2 was the designated Person in Charge. They were not able to correctly discuss or demonstrate effective knowledge in food illnesses that must be excluded or reported, effective cooling methods/procedures, reheating temperatures and process, and effective washing and sanitizing of equipment. Staff 2 indicated they had not fully completed their training, however, was on their own and designated as person in charge.

* Staff were reusing one plate cover when transferring food items to residents rooms. There was no observed satiation step from one resident room to another.

*Staff 2 did not have facial hair restrained as required.

Staff 2 and the surveyor toured the kitchen. Staff 2 acknowledged the above findings.

At 1:45 pm the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Administrator) who acknowledged the findings.

Debris, drips, spills, and splatters of drawers, cabinets, drip pans, sides of stove, microwave, refrigerator, spice shelves, storage closet, and walls behind prep spaces have been deep cleaned. Safety latches and electric can opener have been discarded. Cooking equipment previously stored on top of cupboards has been relocated to storage closet. Hole in closet has been repaired. Open dates added to all foods, including shelf stable ingredients and closed securely. Cooking equipment and utensils sanitized using bleach water bucket sanitizing method. Additional plate covers have been purchased to eliminate the need for sanitation step during meal service.

Daily and weekly cleaning and tasks checklists have been expanded to include equipment storage areas, open dates, and enhanced additional cleaning areas. Thawing, cooling, and bleach sanitation procedures have been reviewed with all dietary staff. Staff 2 is no longer employed. Newly hired dietary personnel will be placed under supervision of qualified trainer until able to demonstrate competency in identified areas through direct observation and return demonstration. Training handouts will be created and kept in Dietary Binder for easy review and reference related to food borne illness, cooling/thawing methods, and sanitation procedures.

Weekly audits of food preparation and storage areas will be conducted by Dietary Manager and reviewed by Administrator. Inspections of storage closet added to Maintenance Director's routine monthly rounds.

Administrator and/or designee will be responsible to ensure and maintain compliance.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained under sanitary conditions and the person in charge (PIC) had appropriate knowledge in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observations were made of the facility kitchen, food storage areas, food preparation, and food service on 08/15/24, from 10:30 am through 11:30 am. The following was identified:

*There were splatters, spills, drips, dust, and debris noted on:

- Drip pan/drawer under stove;

- Exterior of reach-in refrigerator;

- Spice shelves;

- Food storage pantry wall near floor; and

- Ceiling and floor in storage closet.

* The following items were in need of repair:

- Storage closet housing clean equipment and dishes still contained a hole around electrical conduit, allowing potential access points for pests; and

- Missing electrical box cover in food pantry closet.

* Multiple items found stored in reach-in refrigerator were not dated when opened and/or prepared or did not have a use-by date as required.

* A bag of frozen chicken breasts was observed in the reach-in cooler without method to prevent potential drippings from contaminating other items in the refrigerator stored on the same shelf.

* Staff 2 (Cook/PIC) was observed to pour bleach into a sink of soapy water. Staff 2 was not aware that the practice was unsafe. Staff 2 made a bus tub of bleach water and placed several dirty dishes to "soak." When interviewed, Staff 2 described the process of sanitizing dishes in the bleach water soak prior to washing and rinsing. Staff 2 was not able to correctly describe or demonstrate proper wash, rinse, and sanitize process for ware washing.

* The reach-in refrigerator thermometer read 50 degrees Fahrenheit. Multiple food items in the refrigerator were checked and were not at 41 degrees F or below, as required. Staff 2 was unable to verbalize the correct temperature at which cold food must be stored. Food dated 08/14/24 had a temperature of 50 degrees F. A food item from breakfast that morning was at 60 degrees F, and milk was at 51 degrees F. Staff 2 did not know how long the refrigerator was not at appropriate storage temperatures. Upon review of temperature logs, the entry for 08/15/24 documented 40 degrees F. Staff 1 (Administrator) was informed of the elevated temperature of the reach-in cooler and food items, and they indicated the food items would be discarded. Staff 1 contacted maintenance staff to address the temperature issue of the cooler.

* Staff 2 was the designated person in charge. They were not able to correctly discuss or demonstrate effective knowledge of food illnesses that must be excluded or reported, effective cooling methods/procedures, reheating temperatures and process, or effective washing and sanitizing of equipment.

* Upon entry to the kitchen, Staff 2 did not have a hair or beard restraint on and was engaged in kitchen tasks. Staff 2 put on hair restraints upon seeing the surveyor; however, their hair was not effectively covered/restrained.

Staff 2 and the surveyor toured the kitchen. Staff 2 acknowledged the above findings.

At 11:30 am the areas in need of cleaning, repair, and attention were reviewed with Staff 1 (Administrator), who acknowledged the findings.

Drip pans, refrigerator, spice shelves, pantry, and storage closet were deep cleaned. Open space around conduit patched. Outlet plate cover replaced. Undated foods items were discarded. Thawing chicken in plastic bag placed in container on bottom shelf to prevent potential leakage. Dietary staff reviewed proper process order of wash, rinse, then sanitize. Additional training provided to dietary staff regarding safe temperatures for cooking, cooling, and reheating foods and food illnesses that must be excluded or reported. Reach in refrigerator thermometer was inspected and repaired.

Dietary staff schedules rearranged to provide overlap for the purpose of team deep cleaning once per week. Training Binder will be reviewed with cooks once weekly. Administrator will inspect kitchen once weekly for needed repairs and cleanliness, assure hair restraints are in place, thawing procedures are being followed, and daily checklist tasks are completed. Analog thermometer will remain inside reach in refrigerator near the front indefinitely to ensure proper temperatures. Reach in temperatures will be checked and recorded twice daily.

Corrections will be evaluated intermittently and at least weekly for three months and be reinstated any time there is a change in personnel.

Administrator and/or designee will be responsible to ensure and maintain compliance.

Based on observation and interview, it was determined the facility failed to ensure the person in charge (PIC) had appropriate knowledge in accordance with the Food Sanitation Rules OAR 333-150-000 and failed to ensure employees were properly sanitizing cleaned multiuse equipment and utensils before they were reused. This is a repeat citation. Findings include, but are not limited to:

Observations were made of the facility kitchen, food storage areas, food preparation, and food service from 11:15 am through 3:30 pm on 10/15/24. The following was identified:

Upon entering the facility at 11:15 am on 10/15/24, Staff 1 (Administrator) identified herself as PIC as Staff 3 (Cook/PIC) had to step out of the building for a short time. When Staff 3 returned at 11:30 am, she was identified as the PIC. Staff 3 stated she was the main cook Sunday through Wednesday each week.  

At 12:10 pm Staff 3 was observed pouring bleach into a bus tub and adding hot water. She stated the solution was used to soak and sanitize items which did not go through the warewasher, such as knives. She then placed a knife in the solution. Staff 3 did not test the chlorine level of the solution. The surveyor tested the solution and it read as >200 ppm, significantly outside the parameters of 50-100 ppm.

At 12:40 pm, Staff 3 removed the knife from the solution, rinsed it in hot water, and placed it on a hand towel to air-dry. Staff 3 was then observed hand-washing cookware items with soap and a re-useable sponge, rinsing the items, and placing them on the hand towel to air dry. Multiple items, including a plate cover and electric skillet (used to heat the main dish for lunch, sloppy joes) were not sanitized. Staff 3 did not correctly demonstrate proper wash, rinse and sanitize process for ware washing.

At 12:45 pm, Staff 1 and Staff 3 were interviewed about their current process for sanitizing items which could not go through the mechanical warewasher. Staff 1 stated she believed the items were sprayed with Lysol. Staff 3 stated a bleach spray had been used in the past, including spraying and wiping down larger items, but acknowledges she was not currently using any type of sanitizing method for large items. She stated she believed the sanitizing tub was effective for utensils like the knife, and acknowledged rinsing items after soaking them in the tub. Staff 1 and Staff 3 acknowledged that they did not have a current system for monitoring the ppm of the sanitizer solution in the bus tub were not able to state how long items would need to be in the tub in order to be sanitized. Staff 1 and Staff 3 again stated they believed larger items could be wiped with sanitizer and did not need to be submerged, though this was not a part of their current process.

The need for the PIC to have appropriate knowledge in accordance with the Oregon Food Code, including ensuring employees were properly sanitizing cleaned multiuse equipment and utensils before they were reused, was reviewed with Staff 1 and Staff 3 at 1:00 pm on 10/15/24. They acknowledged the findings. At 2:55 pm on 10/15/24, Staff 1 provided information which stated the facility would be immediately changing their processes to ensure employees were properly sanitizing cleaned multiuse equipment and utensils.

Sanitation process completed by utilizing the dishwasher for all items until sanitation tablets could be procured.

Dissolvable sanitation tablets have been purchased with one minute contact time to sanitize multiuse equipment and utensils between dishwasher cycles.

Sanitizing solution will be prepared and tested once per day and replaced if solution becomes diluted or soiled.

Sanitizing process will be inspected intermittently, not less than weekly for one month. Audits of Kitchen sanitation processes will be brought to QAPI Committee each quarter.

Administrator and/or designee will be responsible for compliance

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols, specifically related to hand hygiene, in order to provide a safe, sanitary, and comfortable environment. Findings include, but are not limited to:

Observations were made of the facility kitchen and staff during food preparation and food service from 11:15 am through 3:30 pm on 10/15/24. The following was identified:

*Upon entering the kitchen at 11:15 am on 10/15/24, it was observed that the kitchen had a single sink with two compartments. Staff 4 (Housekeeper/Cook) who was preparing lunch while Staff 3 (Cook/PIC) was out of the facility, stated this was the handwashing sink. There were no paper towels or air dryer available to dry hands after washing. When asked what was used to dry hands, Staff 4 stated she would either wash her hands in the bathroom, or use a reusable washcloth found in the kitchen. To access the reuseable washcloths, she had to place her hand on a drawer knob to open the drawer where towels were located. She stated that after using a washcloth, it was placed in a receptacle in an area which required her to exit the kitchen, to be washed at a future time.

*At 11:30 am, Staff 3 stated she had removed the paper towels from their holder which was located underneath a cabinet near the sink as the electric skillet was being used on the countertop under the paper towel holder. She stated that staff would dry their hands with the reusable washcloths in the drawer. Staff 3 confirmed that there was nowhere to place the washcloths after use without leaving the kitchen.

*At approximately 12:10 pm, Staff 3 was observed on two occasions entering the kitchen after completing non-food-service activities including taking binders, which were utilized by direct care staff, in and out of a cupboard, and then donning gloves and preparing or serving food without performing proper hand hygiene prior to donning gloves.

*At 12:15 pm, Staff 5 (CG) was observed serving food to residents without performing proper hand hygiene prior to donning gloves.

*At 12:30 pm, Staff 3 returned to the kitchen area stating "I just had to run to the bathroom" and proceeded to don gloves and plate and serve food without performing proper hand hygiene.

The need to establish and maintain infection prevention and control protocols, specifically related to hand hygiene, in order to provide a safe, sanitary, and comfortable environment was reviewed with Staff 1 at 3:30 pm on 10/16/24. She acknowledged the findings.

Paper towel bar installed near handwashing area. Bussing tubs will be used to collect dirty dishes to keep sink clear for handwashing. Trash can to dispose of paper towels has 'hands-free' opening feature.

Training provided to staff on proper hand hygeine, to include the necessity of performing hand hygeine upon entry to kitchen, using disposable paper towels only for drying, and washing hands between glove changes.

Meal service will be inspected intermittently, no less than weekly, for one month. Audits of kitchen infection control practices will be brought to QAPI Committee each quarter.

Administrator and/or designee will be responsible to ensure compliance.

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.

Refer to C240

Based on observation and interview, 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.

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. Findings include, but are not limited to:

Refer to C240.

Refer to C 240

Based on observations and interviews, 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 observations 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 and C 295.

Refer to C240 and C295