Print Inspection: TPUV

The findings of the kitchen inspection, conducted 08/08/24 through 08/09/24, 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 revisit to the kitchen inspection of 08/09/24, conducted 10/10/24 through 10/11/24, 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 08/09/24, conducted 01/02/25, 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 ensure each resident's dignity with dining was maintained by failing to ensure resident likes and preferences with meals were honored, along with ensuring wait times for meals were reasonable for 1 of 1 sampled resident (#1). Findings include but are not limited to:

Resident #1 was admitted to facility on 11/09/17 with diagnoses including major depressive disorder and Alzheimer's disease.

The resident's diet order, dated 09/27/23, was regular/general/house diet, mechanical dental soft: ground texture, and thin/regular consistency. The resident face sheet indicated his/her spouse was his/her Power of Attorney for financial and care decisions and listed the resident's daughter as emergency contact number two.

The resident's service plan was reviewed and documented the following:

* Eating/Meals - Initiated 08/16/22, revised 01/09/24: "[Resident name] requires staff assistance in ordering or choosing menu items...[Resident name] enjoys soft foods...due to missing teeth. serve milk with every meal per family request. [Resident] enjoys breakfast foods such as scrambled eggs, French toast, and pancakes..."

* Diet - Initiated 08/16/22, revised 04/04/24: "Diet - Mechanical Soft Diet: Ground. Daughter would like input in [his/her] menu Choices, Make this available to her. High protein choices when she is not available. Breakfast choose eggs and sausage, NO pancakes, french toast or syrup on [his/her] plate. Lots of meat few carbs and make sure vegetables are bite size portions."

Progress notes documented on 04/04/24, "Care conference held today with daughter. Daughter does not want syrup or pancakes, high protein. Meats should be chopped more..."

On 08/08/24, during the facility's annual kitchen inspection, the lunch meal was observed. The meal cart from the kitchen arrived to the South unit, where Resident 1 resided, at approximately 11:10 am. At 11:35 am, caregivers began dishing out resident meals. Surveyor observed staff dish out three plates of pureed menu choices. Surveyor asked how many residents received altered texture diets. The staff response was one puree and two mechanical soft. Surveyor asked why three plates of puree were dished out, and the staff member replied that there were no mechanical soft items sent from the kitchen that meal. Staff decided not to serve the pureed texture to Resident 1, but stated they would contact the kitchen for a mechanical soft meal. Resident 1 was sitting at the table with beverages at this time. At 12:25 pm, the resident was observed still at the table with beverages, but no food. Surveyor asked care staff if kitchen had provided any mechanical soft food items yet, to which they replied, "No, not yet."

Surveyor went to main kitchen and observed three containers of mechanically altered food items sitting on the warming line ready for service. Surveyor observed line cook asking another kitchen staff to take the mechanically altered items to memory care. Surveyor followed food items to South unit. Care staff immediately began dishing up a serving of finely chopped carrots, mashed potatoes, and finely diced/ground BBQ meat into one bowl. Staff was then observed to open a container of applesauce and pour over meal items and mix entire content of bowl together. Surveyor asked care staff if that was how Resident 1 preferred his/her meals. Staff replied, "No, this is what [his/her] daughter wants us to do." Surveyor asked staff if they knew why, and they replied, "No, but it's gross. [Resident] doesn't eat it. Maybe [his/her] daughter wants [him/her] to have more fruit?" Staff then stated that the daughter "makes" them serve all the resident's meals like this with all food items mixed together with applesauce. Staff also indicated they are not allowed to give the resident pancakes or French toast at breakfast, which the resident likes. Per the resident's daughter, they were to serve only "scrambled eggs, bacon, and/or sausage with apple sauce mixed in. It's so gross, [s/he] never eats it." Resident 1 was served his/her lunch at 12:35 pm, an hour after other residents were served their meal.

On 08/08/24 at 12:45 pm, Staff 2 (Dining Services Director) was interviewed regarding the extended time for mechanical soft to be provided to Resident 1. Staff 2 stated that one hour was definitely too long and not typical. Staff 2 was not sure why pureed items were originally sent for all mechanically altered residents and agreed that was not appropriate. Staff 2 indicated that the line cook that usually takes care of the mechanically altered items was "slammed" that meal service and acknowledged that the kitchen should have gotten the right textured food to the resident more quickly.

Staff 1 (Executive Director) and Staff 5 (Memory Care Administrator) were interviewed on 08/09/24 at 11:10 am. Both acknowledged that Resident 1 waiting an hour to receive their mechanically altered food items was unacceptable. Neither Staff 1 nor Staff 5 were aware that staff were combining all of the resident's food items and mixing in applesauce at all meals. Both Staff 1 and Staff 5 acknowledged that practice was not appetizing, with a high potential for the food to not be palatable for most individuals.

Staff 1 and Staff 5 were asked to provide documentation that Resident 1's daughter was power of attorney to make care decisions for him/her. No documentation could be located prior to survey exit. Both Staff 1 and Staff 5 acknowledged that the resident had a right to eat foods that they liked and in a way that they liked/preferred. Staff 1 acknowledged that Resident 1 did not have any medical diagnoses that would indicate the need for a reduced carbohydrate and high protein diet. Staff 1 acknowledged there was no diet order to indicate that a carbohydrate restricted diet would be appropriate for the resident.

C200

The following actions will be taken to correct the violations:

An audit of all MC resident's diet orders will be completed by the AED/WD/RSD to itentify and address any discrepancies or errors

Inservice training session will be conducted by DSD with all dining associate on preparing special texture diets, and the importance of safety for residents requiring special dietary needs. This to include a hands-on demonstration of preparing puree and mechanical soft textures to help with ensuring accuracy and consistency.

Inservice training session with ALL associates reviewing the key rights guaranteed to residents, including the right to be treated with respect, privacy, and dignity.

Inservice training session will be conducted by DSD with all dining associates on timeliness of order processing, preparation, and delivery

Inservice training session with all MC associates regarding POA, where to find the POA information, and that a POA is the designated individual with the authority to act on behalf of the resident

Diet board created identifying which residents have a special texture diet.  The board will be visible in the main kitchen to all dining associates.  It will be maintained by the DSD/WD

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident's dignity with dining was maintained by failing to ensure resident likes and preferences with meals were honored, along with ensuring meals were appetizing/palatable for 1 of 1 sampled resident (#1). This is a repeat citation. Findings include, but are not limited to:

Resident 1 was admitted to facility on 11/09/17 with diagnoses including major depressive disorder and Alzheimer's disease. Resident 1 was non-interviewable.

A Faxed copy of "health care provider's orders" dated 09/11/24 documented: "Please confirm the diet we have on file: Mechanical soft, decreased carbs, increased protein. Food in bowl & (and) apple sauce added. Regular thin, liquids...Do you agree?" The box of "yes" was marked and the statement, "agree to above," was documented.

The resident's service plan was reviewed and documented the following:

* Eating/Meals - Initiated 08/16/22, revised 01/09/24: "[Resident name] requires staff assistance in ordering or choosing menu items...[Resident name] enjoys soft foods...due to missing teeth. serve milk with every meal per family request. [Resident] enjoys breakfast foods such as scrambled eggs, French toast, and pancakes..." A addition on 08/22/24 documented "Resident requires hands on assistance to complete meal (Specify:)."

* Diet - Initiated 08/16/22, revised 04/04/24: "Diet - Mechanical Soft Diet: Ground. Daughter would like input in [his/her] menu Choices, Make this available to her. High protein choices when she is not available. Breakfast choose eggs and sausage, NO pancakes, french toast or syrup on [his/her] plate. Lots of meat few carbs and make sure vegetables are bite size portions."

On 10/10/24 at 11:45 am  Resident 1 was observed with lunch meal served. The resident had a large bowl of ground food products in front of her that she was feeding herself. The food products were all of similar color and texture. Care staff were interviewed and stated that they were directed to put all food items in one bowl and mix in a container of applesauce for all meals. Staff were asked if that was the resident's preference and they stated it was not, that it was directed from the resident's daughter.  

On 10/10/24 at 12:45 pm, Staff 2 (Dining Services Director) was interviewed and was asked why all food items for Resident 1 were served in the same bowl, mixed all together with applesauce. Staff 2 indicated to her knowledge it was related to the wishes and direction of the resident's daughter. Staff 2 acknowledged that serving foods all blended together with applesauce would not be appealing/palatable to most people. Staff 2 verified to their knowledge that was not a preference for the resident to have her meals delivered in this way.

Interview with Staff 3 (Business office manager) and Staff 4 (Resident services director) at 1:00 pm revealed the reason staff combined all meal/food items together was related to the daughter insisting the meals be served that way. Staff were not able to provide any documentation or other evidence to support the mixing of food items was the residents choice. They acknowledged that they themselves would not wish to consume their meals in this manner. Staff 3 and Staff 4 were asked why there was a carbohydrate restriction for the resident. They confirmed it was at the request of the daughter.

Staff 1 (Executive Director) and Staff 5 (Memory Care Administrator) were interviewed 10/11/24 at 10:00 am. Both acknowledged that they were aware that staff were combining all of the resident's food items and mixing in applesauce at all meals. Both Staff 1 and Staff 5 acknowledged that practice was not appetizing, with a high potential for the food to not be palatable for most individuals. Staff 1 and 5 confirmed the facility had not attempted alternatives to the mixing food together for meals to increase independence with eating. Staff 1 and 5 acknowledged the facility continued to restrict access to carbohydrate rich foods including those identified per resident likes that the resident enjoyed at the request of the resident's daughter. The facility failed to ensure Resident 1's right to eat the foods they enjoy/liked by restricting carbohydrates as well as, the right to receive food in a way that was appetizing and palatable.

The following actions will be taken to correct the violations:

1. Resident 1 service plan was updated with likes and preferences for meals; Hospice clarified texture, and how to present it in a way that is appetizing and palatable. Care conferences were held with family and POA on 10/14/24 and 10/17/24 to review resident #1 dining preferences and resident right to receive food that is appetizing and palatable. On 10/17/24, two in-services were conducted with memory care associates to review and educate about Residents Rights and Protections, OAR 411-054-0027. Dietary boards in memory care kitchens and main kitchen were updated with current diet and texture orders.

2. The system will be corrected by the following steps and to assure it doesn't happen again: We obtained current diet and texture orders for all memory care residents and entered diet orders into electronic health care record.

3. Diet orders will be reviewed weekly.

4. Dining Services Director, Associate Executive Director, and Executive Director, and Licensed Nurse will be responsible to see that the corrects are completed and monitored.

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

Observation of the main facility kitchen and the memory care unit kitchenettes on 08/08/24, from 10:15 am through 1:45 pm, revealed the following deficient practices:

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:

* Removable hood vents;

* Floors in corners and edges throughout kitchen;

* Floor under and behind major equipment;

* Floor under and around ware washing area;

* Walls behind and beside grill, flat top, and fryer;

* Corners, edges, and front of gas flame grill;

* Interior and exterior of convection oven;

* Industrial slicer;

* Table top equipment (blender/food processor);

* Industrial mixer;

* Walk-in freezer and cooler floors;

* Metal racks holding meat products in walk-in cooler;

* Movable "Go" racks in walk-in:

* Metal utility cart holding fan;

* Fan blades, cage, and base;

* Open stainless steel shelving throughout kitchen;

* Reach-in coolers and freezers;

* Wall under hand washing sink;

* Ice scoop holder; and

* Door grate for elevator floor off of main kitchen leading to dry storage/memory care unit with heavy food/dirt debris noted in crevices.

b. The following areas needed repair:

* Sections of caulking in ware washing area with black matter debris and build-up;

* Deli fridge plastic door striping damaged and peeling off; and

* Holes by duct work in dry storage with greater than 1/4 inch gap needing to be sealed to prevent potential pest entry.

c. Dietary employee observed to serve hot dogs off the grill without checking temperature to ensure they reached the required 165 degrees. Surveyor asked employee to check temperature and both hot dogs were above 165 degrees; however, the kitchen employee was going to serve the food product to residents without first validating the appropriate and safe temperature was reached.

d. Multiple dietary employees were handling clean dishes or preparing food without appropriate hair or facial hair restraints.

e. Multiple food items were found uncovered/unprotected from potential contamination while stored in reach-in and/or walk-in coolers or freezers.

f. Multiple food items were found without open dates and/or without use-by dates or past seven days per food code.

g. Staff lunch container was noted to be stored in reach-in refrigerator storing resident food.

h. North unit kitchenette revealed areas in need of cleaning:

* Microwave and reach-in oven with dried food debris, spills, and splatters;

* Multiple items located in reach-in refrigerator were not dated when opened or were noted to be past the seven days; and

* One opened container of cottage cheese was past seven days and had visible mold growth on/in food product.

i. South unit kitchenette revealed the following areas in need of cleaning:

* Reach-in refrigerator with spills, splatters, and food debris;

* Oven with dried on-food debris;

* Reach-in refrigerator with multiple undated food items; and

* Staff food/beverages stored with resident food.

Staff 2 (Dining Services Director) toured the area with surveyor and acknowledged areas in need of cleaning and attention. In an interview on 08/08/24, at 1:45 pm, Staff 1 (Executive Director) was informed of concerns found and acknowledged areas needing correction.

C240

The following actions will be taken to correct the violations:

a. The following items have been thoroughly cleaned

*Removable hood vents

*Floors in corners and edges throughout kitch

*Floor under and behind major equipment

*Floor under and behind ware washing area

*Walls behind and beside grill, flat top, and fryer

*Corners, edges, and front of gas flame grill

*Interior and exterior of convection oven

*Industrial slicer

*Table top equipment (blender/food processor)

*Industrial mixer

*Walk-in freezer and cooler floors

*Metal racks holding meat products in walk-in cooler

*Movable "Go" racks in walk-in

Metal utility cart holding fan

*Fan blades, cage, and base

*Open stainless steel shelving throughout the kitchen

*Reach-in coolers and freezers

*Wall under handwashing sink

*Ice scoop holder

*Door grate for elevator floor off of the main kitchen

All of the above items will be monitored weekly by Dining Services Director/AED/ED

b. The following areas have been repaired:

*Sections of caulking in ware washing area completed by POD

*Deli fridge plastic door stripping replaced by Clay's Refrigeration

*Holes by duct work in dry storage were sealed by POD to prevent potential pest entry

c. Inservice training session will be conducted by the DSD with all dining associates on food safety, proper temperature usage, key temperature guidelines, and best practices when serving food

d. Inservice training session will be conducted by DSD with all dining associates on food safety, why hairnets and facial restraints are crucial, proper usage, and best practices. DSD/AED/ED will monitor daily for compliance

e. Inservice training session will be conducted by DSD with all dining associates on food storage safety, proper labeling and covering of all items stored in the freezer and/or walk-in cooler.  DSD/AED/ED will monitor daily for compliance

f. Inservice training session will be conducted by DSD with all dining associates on food storage safety, proper labeling and covering of all items stored in the freezer and/or walk-in cooler.  DSD/AED/ED will monitor daily for compliance

g. Inservice training session will be conducted by DSD with all dining associates on proper food storage and potential cross contamination when associate lunch containers are stored in designated resident refrigerators .  DSD/AED/ED will monitor daily for compliance

Based on interview and record review, it was determined the facility failed to ensure 2 of 8 staff (#s 3 and 4) who prepared food had active food handler's certificates. Findings include, but are not limited to:

On 08/08/24 employee records were requested and reviewed to ensure staff had active food handler's cards. The food handler's card for Staff 3 (Cook) was dated as obtained the day of survey. No food card was provided for Staff 4 (Cook). In an interview with Staff 1 (Executive Director) on 08/08/24 at 2:40 pm, surveyor requested to review Staff 3's previous food handler's card of Staff 3 and again requested Staff 4's food handler's card to review.

On 08/09/24 at 11:10 am, the facility provided a copy of Staff 3's former food card, which had expired on 11/06/23. An active food card still could not be located for Staff 4. Staff 1 acknowledged Staff 3 and Staff 4, who prepared food, did not have active food handler's cards upon entry for annual kitchen survey.

An audit of associate records will be conducted by the ED and Business Office Manager.  A tracker will be created and maintained by the BOM.  It will be monitored weekly by the ED/AED/DSD

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 200.

Refer to C200

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 200, C 240, and C 370.

Refer to C200, C240, C370

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 C200 and C455