The findings of the kitchen inspection, conducted 04/23/24 through 04/24/24, 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 04/24/24, conducted 09/06/24, 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.

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 second re-visit to the kitchen inspection of 04/24/24, conducted 11/07/24, 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, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

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 04/23/24 and 04/24/24 showed the following areas were in need of cleaning or repair.

Memory Care Kitchenette:

* Black accumulation at the floor edges and tops of baseboards;

* Spills and splatters to the walls;

* Spills, stains and debris were noted in the cupboards, drawers and drawer edges;

* Debris was noted in the base of the oven; and

* The counter top to the right of the stove was pulling apart at the seam and lifting up at the outer edge.

Main Kitchen:

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

* Multiple broken light covers throughout the kitchen, as well as debris and dead insects within the light covers;

* Back discoloration was noted along the floor edges throughout the kitchen, black accumulation in the doorway floor edges and around the edges of equipment legs;

* Shelving in multiple refrigerator and/or freezer units had spills, debris, black discoloration, rust and chipped/peeling shelf coating;

* Missing laminate pieces were noted on shelves under the steam table with exposed particle board edges;

* Multiple shelves in the dry storage had spills or debris. Debris was noted on the floor underneath shelving units;

* Debris and trash located in the drain under the ice machine;

* Metal shelves throughout the kitchen had white, black or brown clumps of debris, as well as drips and spills;

* Food items stored near the exterior door had dust and debris on the surfaces of the canned goods and bottles;

* Pink food cart was cracked in several areas;

* Plastic barrier on the front of the steam table had food debris, brown stains and was cracked;

* Three pots, two frying pans and several baking/cookie sheets had large amounts of black accumulation at edges, bottoms and/or interiors. The pots and frying pans were dented or warped;

* Three cutting boards were worn with numerous grooves;

* Multiple plastic cup holders were cracked with missing pieces;

* Cereal dispensers were cracked with missing and broken pieces on the upper and lower portions;

* Multiple areas with missing grout near the dish area and bread shelf. Several sections of the floor had significant wear of the grout creating deep grooves between the tiles;

* Missing or discolored caulking was noted around the edges of the counter top at the drink station outside the kitchen;

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

* Baseboard tile near the stove was pulling away from the wall which created a gap between the two surfaces.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Executive Director) and Staff 2 (Executive Chef) on 04/24/24. The staff acknowledged the findings.

1)  Kitchen floors will be deep cleaned, regrouted, and sealed by outisde contracter.

-Doorway has been cleaned and repainted.

-Broken light covers were replaced and all light covers were cleaned out.

-Exposed particle board below steamer has been painted and sealed.

-All shelving that is missing coating will be recoated or replaced.

-Drain under ice machine has be cleaned.

-Baseboard tile near stove will be fixed.

-Missing and discolored caulking will be cleaned and/or recaulked.

-Pink food cart is being replaced with a new cart.   

-cup holders, pots, pans, and cutting boards that were noted to not be in good condition or cracked have been replaced with new.

-Cereal dispenser will be preplaced with a new one.

-Kitchen was deep cleaned and all drips, dust, splatters, and debris noted were cleaned.  Also all equipment legs have been cleaned.

-Sneeze Gaurd will be removed or replaced.

Memory Care kitchenette was deep cleaned and all spills, splatters, debris, stains, and black accumulation are removed.

Countertop that is pulling apart will be replaced with a new countertop.

2)  Dining staff will be provided retraining on cleaning expectations and signing off on task logs for kitchen.

3)  Executive Chef (EC) will monitor compliance weekly by checking the cleaning and task forms.

4)  The Executive Chef and Environmental Service Director are responsible for 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. This is a repeat citation. Findings include, but are not limited to:

Observations of the kitchen on 09/06/24 from 12:20 pm through 1:45 pm showed the following areas were in need of cleaning or repair.

* Dust, dirt and debris was noted on walls and ceilings throughout the kitchen;

* Dust, dirt and debris was noted on multiple ceiling vents;

* Dust, dirt and debris was found on metal shelving holding clean dishes;

* Multiple kitchen staff noted to be preparing and/or serving food without facial hair restrained as required per rule;

* Black discoloration was noted along the floor edges throughout the kitchen, black accumulation in the doorway floor edges and around the edges of equipment legs, under and behind cooking equipment and food storage shelving;

* Missing or discolored caulking was noted around the edges of the counter top at the drink station outside the kitchen;

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

* Frozen chicken and ground beef was observed sitting in pans and a large container of chicken was in the sink. Non of these containers were under continuous cold running water. Staff was asked what was happening with those products and staff indicated they were thawing those items. Staff validated they were not under cold running water. Staff confirmed the containers they were in would not allow the food items to be fully submerged under running water. Staff stated those food items were for the next day and they intended on thawing them out for a while then putting back into the cooler to cook the next day. Staff was unaware of the correct process for quick thawing meat products.

* Memory Care Kitchenette was reviewed and found:

- Spills, stains and debris were noted in the cupboards, drawers and drawer edges;

- Spills, splatters and debris noted in the microwave;

- Spills, dust, dirt, and debris found on the floor and in corners/edges; and

- Debris was noted in the base of the oven.

At 1:30 pm, the identified areas of concern were discussed with Staff 1 (Executive Director) who acknowledged the need for continued correction of these items.

1) Dust, dirt and debris on walls and ceilings throughout the kitchen, ceiling vents and metal shelving holding clean dishes were cleaned and added to a daily/weekly cleaning schedule.

Hair nets will be worn for any staff that have facial hair to keep restrained as required per rule.  Training has been done with all kitchen staff on 9/10/2024

Black discoloration along the

floor edges throughout the kitchen, black

accumulation in the doorway floor edges

and around the edges of equipment legs,

under and behind cooking equipment were cleaned and task was added to the daily/weekly cleaning task sheet.

Missing/discolored caulking around the edges of the counter and top of drink station and debris, spills and stains in drawers was addressed by having a new counter and cuboard set installed.

Staff was unaware of the correct process for quick

thawing meat products.  Staff have been retrained on safe meat thawing practices.

Memory Care kitchenette:  Spills, stains and debris noted incupboards, drawers and drawer

edges; Spills, splatters and debris noted in the

microwave; Spills, dust, dirt, and debris found on

the floor and in corners/edges; and Debris noted in the base of the oven have been cleaned and cleaning has been added to a daily/weekly cleaning task list.

2)  Dining staff will be provided retraining on safe meat thawing, cleaning expectations, and signing off on task logs for kitchen.

3)  Executive Chef (EC) will monitor compliance Daily/weekly by checking the cleaning and task forms.  MC Admin will monitor compliance cleanliness of Memory Care Kitchenette.

4)  The Executive Chef and Environmental Service Director are responsible for compliance.

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.

See C240

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.

see C 240

Based on observations and interviews, 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.

See C240