The findings of the kitchen inspection, conducted 5/9/23, 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 first revisit for the kitchen inspection on 05/09/23, conducted 06/29/23, 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 06/29/23, conducted 10/02/23, 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 third revisit to the kitchen inspection of 05/09/23, conducted 02/27/24, 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 fourth revisit to annual kitchen inspection of 05/09/23, conducted 07/15/24 through 07/17/24, 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, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the six house kitchens on 5/9/23 at 10:25 am through 2:00 pm revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Window seals;

* Kitchen drains;

* Ceiling, fire sprinklers and vents;

* Interior and exterior of microwaves;

* Stove/grill/oven knobs, doors, interior, exterior;

* Hood above grill/stove with large accumulation of dirt/grease debris on removable vent covers;

* Large can openers and housings;

* Light fixtures and areas of ceiling;

* Reach in refrigerators and freezer handles, exteriors and interiors in all kitchen areas;

* Floors in all kitchen areas;

* Ice machine with mold like substance in interior as well as mineral build up;

* Thresholds and corners with build up of dirt/debris;

* Wood door ways;

* Plastic shelving in dry storage area;

* Cambro food carts; and

* Walls with spatter/drips/dust.

b. The following areas were found in need of repair:

* Dishwasher hood vent rusted and with dust buildup;

* Multiple light fixtures broken/cracked;

* Laminate flooring with cracks/tears, chips in multiple areas/buildings;

* Window screens with holes;

* Gaps in windows near air conditioning units allowing dust/dirt/debris/pests to enter kitchen areas;

* Some windows with build up of black mold like substance;

* Microwave in kitchen with rust/damage making un-cleanable surfaces in interior;

* Multiple metal shelves with damage and/or rust;

* Wooden shelves with damage/exposed wood and not smooth/cleanable surfaces;

* Vents/fire sprinklers in kitchen with dust/dirt build up;

* Interior refrigerator shelving with areas of pealing and exposed metal which was covered in a rust type substance;

* Gaps in some of the sprinkler mounts;

* Cove base loose, warped and pealing off wall in areas;

* Multiple pots/pans with darkened carbon and grease debris; and

* Accumulation of water under prep areas/sinks with saturated towel on the floor.

c. Food items found in refrigerator and freezers that were not covered to prevent potential contamination. Multiple food items found without dates when opened and/or prepared. Multiple potentially hazardous food items past their manufactured listed use by dates.  

d. Multiple cutting boards found to be heavily scored and/or stained. Food contact surfaces of equipment not covered or protected from contamination when stored.

e. Facility was not monitoring dishwasher to ensure effectively sanitizing dishes/utensils.

f. Facility not using pasteurized eggs for soft/undercooked egg items.

g. Shell eggs stored directly above bags of shredded chesses. Produce items stored on raw bacon case/box.

h. Sanitizing rags stored on counter and were visibly soiled. Kitchen staff unaware of proper concentration of sanitization solution and was found prepared at a higher concentration than recommended.

i. Kitchen staff with long acrylic nails were not using gloves during meal service. Multiple kitchen staff preparing and service foods without hair/facial hair restrained. Kitchen staff observed to touch ready to eat food items with bare hands. Staff not observed to wash hands between tasks to prevent potential contamination.

j. Mop buckets and mop stored next to clean/sanitized dishes.

k. Multiple hand washing sinks were without soap and/or paper towels to ensure ability for staff to effectively wash hands upon entry to kitchen areas and when hands were potentially soiled or contaminated.  One kitchen staff was observed to wash hands in the 3 compartment sink instead of dedicated hand washing station sink.

l. Meals delivered to resident rooms were not covered to protect from potential contamination during transport.

Staff 2 (Dietary Services Director)  and Staff 1 (Executive Director) toured the kitchen areas with the Surveyors on 5/9/23. They acknowledged the above areas needing cleaning/repair and attention.  

Community to put in place new cleaning schedules and calendars to ensure proper throurough completion the Food Service Manager will audit all kitchens on a weekly basis and Executive Director with Food Service Manager will inspect together one kitchen for cleanliness and to ensure good repair.  

Broken or cracked light fixtures have been ordered and will be replaced no later than 6/15/23.

Sherwin Williams Flooring coming to the community to provide needed repairs to laminate flooring.

Screen ordered and will be replaced no later than 6/15/23.

Two microwaves have been disposed of and new microwaves have been ordered.

Wood shelving in 940 and 950 to be removed and replaced with stainless steel wire racks.

Review all surfaces with maintenance for cleaning and repair.

All refrigerators to be audited on a weekly basis to ensure no hazaradous food, all food covered and dated.

All cutting boards were replaced by 5/19/23.

In-services to be held on 5/25/23 to cover dishwasher logs, red buckets and sanitizing logs as well as gloves, hairnets and beard nets.

Hats ordered for all cooks.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the six house kitchens on 06/29/23 at 9:30 am through 12:00 pm revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Windows, window frames, and window seals;

* Kitchen drains;

* Stove/grill/oven interior and exterior;

* Light fixtures and areas of ceiling;

* Reach in refrigerators and freezer interiors;

* Wood dry storage shelves were observed with an accumulation of ants;

* Thresholds and corners with build up of dirt/debris; and

* Walls.

b. The following areas were found in need of repair:

* Flooring with cracks/tears, chips in multiple areas/buildings;

* Some windows and window frames with build up of black mold like substance;

* Microwave interior with rust/damage making an un-cleanable surface;

* Multiple metal preparing tables with damage and/or rust; and

* Multiple pots/pans with darkened carbon and grease debris.

c. Food items found in freezer were not covered to prevent potential contamination and were found without dates when opened and/or prepared.

d. Kitchen staff preparing and serving foods was observed without hair being restrained.

e. Hand washing sink was without soap to ensure ability for staff to effectively wash hands.  

On 06/29/23, Staff 1 (Executive Director) and Staff 2 (Dietary Services Director) toured the kitchen areas and the above areas needing cleaning/repair. They acknowledged the findings.

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

Observation of the six house kitchens on 10/02/23 between 9:30 am and 11:00 am showed the following areas were in need of cleaning or repair:

* Windows, window frames, and window seals had black accumulation, dirt, debris and dead insects;

* Reach in refrigerators and freezer interiors had numerous spills, splatters or debris on doors and shelves. Multiple units had broken or missing pieces from interior shelves or doors;

* Wood shelves in the dry storage areas had chips and scrapes with exposed wood;

* Black accumulation was noted to baseboard edges and thresholds;

* Microwaves in three houses had significant splatters and spills on the interior of the units;

* Flooring in multiple areas/houses had cracks, tears, missing pieces or bubbling up at the edges near drains and walls; and

* Multiple sheet pans had darkened carbon and grease debris.

Staff 2 (Culinary Services Director) toured all areas in need of cleaning or repair with the surveyor, on 10/02/23. The areas in need of cleaning and repair were discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.

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

Observation of the six house kitchens on 02/27/24 between 11:00 am and 12:45 pm showed the following areas were in need of cleaning or repair:

* Windows, window frames, and window sills had black accumulation, dirt, debris and dead insects;

* Reach in refrigerators and freezer interiors had numerous spills, splatters or debris on doors and shelves. Multiple units had broken or missing pieces from interior shelves or doors;

* Wood shelves in the dry storage areas had chips and scrapes with exposed wood;

* Black accumulation was noted to baseboard edges and thresholds;

* Microwaves in three houses had significant splatters and spills on the interior of the units;

* Flooring in multiple areas/houses had cracks, tears, missing pieces or bubbling up at the edges near drains and walls;

* Multiple sheet pans had darkened carbon and grease debris;

* Multiple cutting boards with staining and heavily scored;

* Outside garbage/refuse area with trash/debris on the ground created an area which could attract rodents/pests;

* Multiple items found in reach-in refrigerators without open dates/prepared dates/use by dates as required;

* Floors in multiple kitchen areas found with dirt debris/food debris/splatters/spills;

* Large blanket towels were found under sink in building 910 saturated with water and a slow draining sink;

* Hood vents in building 940 and 950 with large accumulation of dirt/dust/grease debris;

* Ceiling vents with noted dust/dirt/debris;

* Microwave in building 910 was damaged with non smooth/cleanable surface;

* Building 950 had large hole in the ceiling directly over food prep surfaces/area where items from ceiling could potentially fall into or onto food and equipment;

* Multiple food items in dry storage were found open to potential contamination or not securely closed and dated when opened;

* Multiple kitchens had sponges for cleaning equipment that had chunks and pieces missing;

* Multiple reach-in fridges had staff food or beverages stored with resident food; and

* Food service stainless steal cart and hotel pan found stored in garbage/refuse area, staff member then observed taking to a house/building. Unknown amount of time food service equipment stored near garbage/refuse.

Staff 2 (Culinary Services Director) toured all areas in need of cleaning or repair with the surveyor, and acknowledged the issues. The areas in need of cleaning and repair were discussed with Staff 1 (ED) and Staff 2. They acknowledged the multiple findings.

Based on interview and record review, it was determined the facility failed to ensure staff member's whose duties included preparing food, had a food handler's certificate for 1 of 6 sampled employees (# 3) whose food handler's card were requested.  Findings include, but are not limited to:

There was no documented evidence Staff 3 (Cook) had a food handlers card when the surveyors entered the facility for the annual kitchen survey.

Ensuring food handler's card were active for employees whose duties included preparing food was discussed with Staff 2 (Dietary Services Director) on 05/12/23 at 10:00 am.  Staff acknowledged the finding.

All employees now have a current food handler card. The missing employee on the date of inspection's card had expired. All food handler cards have been uploaded to ADP as well as printed and placed on the wall in the Food Service Director Office.

Food Service Director has also put expiration dates on the calendar as well as reminders put in her calendar for two weeks prior to expiration.

Based on interview, observation and review of documentation, 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 C 240.

Based on interview, observation, and record review, 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 and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C240.

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.

Community to put in place new cleaning schedules and calendars to ensure proper throurough completion the Food Service Manager will audit all kitchens on a weekly basis and Executive Director with Food Service Manager will inspect together one kitchen for cleanliness and to ensure good repair.  

Broken or cracked light fixtures have been ordered and will be replaced no later than 6/15/23.

Sherwin Williams Flooring coming to the community to provide needed repairs to laminate flooring.

Screen ordered and will be replaced no later than 6/15/23.

Two microwaves have been disposed of and new microwaves have been ordered.

Wood shelving in 940 and 950 to be removed and replaced with stainless steel wire racks.

Review all surfaces with maintenance for cleaning and repair.

All refrigerators to be audited on a weekly basis to ensure no hazaradous food, all food covered and dated.

All cutting boards were replaced by 5/19/23.

In-services to be held on 5/25/23 to cover dishwasher logs, red buckets and sanitizing logs as well as gloves, hairnets and beard nets.

Hats ordered for all cooks.

Based on observation, record review 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.

Based on observation, record review 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.

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.