Desire for Healing Inc.

“Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner, ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules), and that memory care residents were served food that was palatable. Findings include, but are not limited to: On 07/29/25, from 10:44 am to 2:16 pm, interviews with staff and observations of the facility kitchen, food storage areas, food preparation, and food service were conducted. The following was identified: 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: * Flooring throughout; * Walls throughout; * Interior and exterior of the ice machine; * Exterior of the enclosed food cart; * Multiple food carts in the kitchen; * Large box fan stored next to the ice machine; * Exterior of the ware wash machine; * Small open storage rack to the right of the back exit door; * Multiple windowsills, windows, and window frames; and * Two floor vents located under shelving units on the right wall of the kitchen. b. The following areas were noted in need of repair: * There were cracks noted in the flooring material, recorded from four to 18 inches in length, near the ice machine, to the left of the entrance doors that led to the Kitchen Manager’s office, near the corner of the wall located under a mounted fire extinguisher, under the preparation table located across from the oven, and approximately six feet from the entrance doorway that led to the RCF dining room; * There was a small rectangular section removed from the flooring near the back door exit, recorded at approximately three quarters of an inch by one and one-half inches; * The seams/transitions located under and/or around the two compartment sinks and food preparation station across from the oven, were observed to have missing material and/or needing to be re-sealed; * There were two small areas noted near the entry door and back exit door, where the wall base had been repaired; however, the repaired sections were not repaired in a way to ensure the flooring and wall base were continuous and coved with the floor and tightly sealed to the wall; * The oven on the right was not in working order; * The front of the ice machine lacked hardware that secured parts together; * The wall below the dish pit, to the left of the ware wash machine, had a rectangular hole, recorded approximately 14 inches in length; * The green hood vent above the stove had peeling and chipped paint; * Two ceiling light coverings were cracked and/or broken; and * There was an unfinished wood pallet under the ware wash area. At 11:28 am, Staff 2 (Kitchen Manager) reported since he’s been the Kitchen Manager, the cracks in the flooring had been “filled regularly” by facility maintenance staff. c. One garbage can was observed uncovered throughout meal service. d. The kitchen did not have a separate janitor closet or alcove provided with a floor or service sink and storage for cleaning tools and supplies. e. Facility staff were not observed to check food temperatures prior to transporting it from the kitchen to the memory care. At 11:49 am, Staff 2 reported food temperatures were completed by memory care staff to ensure hot food was held and served within the required temperature. However, there were no observations of staff checking the temperature of the food prior to serving the memory care residents. At 12:10 pm, temperatures were taken by this surveyor. Shrimp temperatures were recorded between 101.2 degrees Fahrenheit and 102.8 degrees Fahrenheit, and noodles with white sauce were recorded at 104.1 degrees Fahrenheit. These temperatures did not meet the required holding temperature of 135 degrees Fahrenheit. On 07/29/25 at 1:36 pm, Staff 2 toured the kitchen with this surveyor and reviewed the areas that were not clean and/or in good repair, the need for hot foods to be held hot, and for meals in the memory care to be served at the required temperature and be palatable. On 07/29/25 at 1:51 pm, Staff 1 (Administrator) and Staff 3 (Administrative Assistant/HR) toured the kitchen with this surveyor and reviewed the areas that were not clean and/or in good repair, the need for hot foods to be held hot, and for meals in the memory care to be served at the required temperature and be palatable. The need to ensure the kitchen was maintained in a sanitary manner, food was prepared and served in accordance with Food Sanitation Rules, and the memory care residents were served palatable meals, was reviewed with Staff 1 and Staff 3 on 07/29/25 at 2:06 pm. They acknowledged the findings. As an overall response to the survey for both tags C0240 and Z0142, the daily, weekly and monthly cleaning schedules are being reviewed, revised and enhanced to ensure food, kitchen, and dining areas are sanitary and safe for our residents. These cleaning schedules will happily be shared with DHS APD SOQ at the 30-day review. The following format of POC responses correlate to the Summary Statement of Deficiencies: a. * Flooring is being deep cleaned with corners, edges, and around legs of tables, etc. scrubbed (8/20/25). A request for quotes for replacing the flooring is out to flooring installers. We are currently awaiting these quotes. (date of completion unknown) * Walls - have been cleaned (8/14/25). Walls near food prep areas will be wiped down daily. Areas not near the food prep areas will be cleaned on the monthly cleaning schedule and as needed. * Ice Machine - has been deep cleaned (7/30/25). Emptying the ice will be monthly. Deep cleaning the ice machine will be on the monthly cleaning schedule. * Insulated Food Tray Cart for Memory Care - will be deep cleaned (8/25/25) and ongoing as: - interior cleaned as needed - exterior cleaned on the weekly cleaning schedule - wheels/bottom cleaned on the monthly cleaning schedule * Open Food Carts - have been cleaned (8/13/25) and ongoing as: - cleaned as needed/used - total cleaning on weekly schedule * Large Box Fan - has been removed from kitchen (7/30/25) * Small Open Storage Rack to Rt of Back Door - has been removed and replaced with a metal open shelved rack (8/8/25). This will be used for non-chemical cleaning supplies and trash bags * Windowsills - have been deep cleaned (8/13/25) and put on our weekly cleaning schedule * Floor Vent Grates - have been replaced with new grates (8/14/25) and put on the monthly cleaning schedule b. The following items have been repaired or schedueld to be repaired: * Cracks in Flooring Materials - awaiting quotes to replace commercial grade sheet vinyl/linoleum. Date of completion will depend upon installer schedule. * Same as above bullet * These will also be replaced with linoleum or repaired by the 30-day resurvey * Same as first b. bullet ( part of replacing flooring) * Right Side of Oven - Columbia Appliance (Umatilla) came on 8/12/25 and are ordering a regulator - currently awaiting the part and replacement to be fixed as soon as possible. * Missing bolts on front of Ice Machine replaced/repaired (8/14/25) * Hole near ware wash machine will be filled in/closed up (8/21/25) * Peeling Paint on Hood Vent - has been removed and repainted with high-temp paint (8/14/25) * Two Ceiling Light Coverings - replaced/fixed (8/10/25) * Wood Pallet Under Ware Wash Machine - replaced with a solid plastic pallet (8/11/25) c. Open Garbage Can - all kitchen staff have been instructed to keep garbage cans covered with lids except when actively filling them such as cleaning up dishes after a meal. (8/14/25) d. Janitor Closet - DfH does not have a separate janitor closet for the kitchen for chemicals so a stand-along closed and lockable storage cabinet has been ordered to store all the kitchen chemicals not attached to a machine or dispensor. (expected to arrive 8/15/25) e. Not Checking Memory Care Food Tem”

“Based on observation 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 C240. All POC corrections and comments for tag C0240 also apply to Z142 for Memory Care as the food preparation is from the same kitchen. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“The findings of the re-licensure survey, conducted 06/24/24 through 06/27/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. The findings of the re-licensure survey, conducted 06/24/24 through 06/27/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.”

“The findings of the kitchen inspection, conducted 08/30/23, 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. The findings of the kitchen inspection, conducted 08/30/23, 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.”