Tsl Elderhealth and Living Memory Village.

“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 the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility cottage kitchens and facility food storage and distribution areas on 01/08/26 from 10:35 am through 1:15 pm revealed the following deficiencies:”

“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 plan of correction for C240 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:”

“Based on observation, and interviews, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility cottage kitchens and facility food storage areas on 01/10/25 at 10:30 am through 3:00 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: Main food storage and distribution center * Walk in cooler floor; * Reach in freezers; Individual Cottage Kitchens; * Interior of reach in refrigerators and freezers; * Interior kitchen drawers, cupboards and cabinets; * Cupboard/drawer where trash/compost was stored; * Interior of oven (Mt Vernon); * Interior of microwaves; * Dry storage pantry floors; * Floors in outdoor storage areas where reach in freezers located; b. The following areas were found in need of repair: Individual Cottage Kitchens: * Corner cupboards and cupboards storing pots/pans, baking pans observed with damage. * Cedar house cove base missing on the corner between fridge and dishwasher. * Cedar house vent above stove with bent/damaged screen yeilding gaps. c. Multiple cutting boards and cooking pots/pans were found damaged and in poor repair with nonstick coating scratched or worn off. d. Multiple potentially hazardous food items found sored in the individual kitchen reach in refrigerators not labeled or dated. Facility is removing most food items from original manufactured packaging and not putting a use by date on the food package. Multiple items were found dated past seven days from opening or preparing and should have been discarded per rule. In the Diamond Peak house, multiple specific resident food items were found stored in the refrigerator and did not have a date opened/prepared or use by date. Multiple containers of beets were found past the expired date of 01/01/25 that was written on the containers. e. Scoops were observed stored in bulk food items like sugar and coffee where handles touched by staff were touching the food product. f. Package of dough was noted to be stored in the draw marked “For defrosting Meats only.” Multiple open packages of deli meats were observed stored next to and with packaging touching the Bread dough packaging. In Cedar house, a bowl of raw fish was observed stored on the top shelf above ready to eat food items and fresh fruits and vegetables. g. Care staff were observed in all houses assisting resident with meals without protective barriers (full aprons) to minimize potential contamination between care provision tasks and meal service. h. Care staff preparing the meals were not able to identify the sanitizing agents used to sanitize surfaces in the kitchen. Staff were unaware of the effective concentrations for surface sanitation. Multiple houses were not effectively sanitizing food thermometers prior to checking food temperatures or in between food items. One staff member was observed to not sanitize the thermometer after checking temperature of fish before placing thermometer in the dessert potentially contaminating the dessert. The fish was fully cooked and posed a minimal risk to the dessert but the practice was unsafe. Surveyor immediately provided education to the caregiver. i. Multiple food items were found stored in cold and dry food storage that were not appropriately covered/sealed and protected from potential contamination. In Diamond Peak house, a plate of food was set aside for a resident on top of the microwave. The plate of food was not covered to protect from potential contamination or to promote palatable temperatures. In Cascades house, meal service items were noted uncovered at 12:50 pm. Lunch service begins for all houses at 12:00 pm. Staff verified they were finished serving residents lunch service. Food items should be kept covered when possible, to protect from potential contamination but also to promote hot holding temperature requirements. j. The main food storage and distribution building does not have a dishwasher to sanitize food contact utensils/dishes. The area has an one compartment sink. Multiple cutting boards and knives were observed next to the sink. Surveyor asked staff 2 (Food and Supply Coordinator/Person In Charge) what the process was for washing and sanitizing his food contact dishes and equipment as well as other surfaces in the food distribution area. Staff 2 indicated cutting boards, knives and other food contact utensils were washed by hand in the sink observed. Staff 2 acknowledged there currently was not a sanitation step as required per rule. Staff 2 was not aware a sanitize step was required. Staff 2 was also not aware of the surface sanitation chemicals used nor the needed parts per million (PPM) to ensure effective sanitation as required per rule. Staff 2 indicated maintenance department mixed the sanitation chemicals for all the houses. At 2:45pm Staff 1 (Executive Director) was interviewed and verified the maintenance department mixed chemicals for surface sanitation. Staff 2 did not know the chemicals or PPM needed for effective surface sanitation per rule. Staff 2 indicated the maintenance director was not at the facility for surveyor to interview. Surveyor asked to be provided the chemicals used and the PPM it was being mixed to along with other written information about the sanitizer used for surfaces and food contact surfaces. At the time of this report no further information was provided to ensure chemicals used were food grade and appropriate concentrations and timelines were followed. k. Multiple kitchens were observed to have uncontained fly trap devices stored in the food preparation and service areas. The traps were full with multiple dead insect carcasses which were clearly visible to residents, staff and visitors. Surveyor discussed this with Staff 1 who was unaware these style of insect traps were not appropriate in food preparation and service areas. l. Staff drinks were observed stored on the counters and or in reach in refrigerators and were not of approved styles. Multiple soda bottles were noted and did not have lids, straws or handles as outlined in rule. Staff drinks must be in a secure/separate area and of the right style to minimize/prevent potential cross contamination. Staff 2 was not aware of the specific style requirements. m. The facility was composting organic material. The individual houses did not have appropriate composting containers that had securely fitting lids to minimize access, attraction and accumulation of pests. The curbside containers utilized were not being cleaned at a frequency to minimize odor and had a great accumulation of food, dirt and debris. This practice could attract pests to the refuse area of the facilities if not maintained as outlined in rule. a) The main food storage and distribution center: walk in cooler and reach in freezers were deep cleaned; all accumulation of food spills, splatters, loose food, trash debris, dirt, dust and black matter/grease was removed. - completed 1/27/2025 Each reach-in refrigerator and freezer has been cleaned by the resident coordinator for each home. -completed 1/24/25. Interior and exterior of kitchen drawers, cupboards, and cabinets are in process of being deep cleaned. All drawers and cupboards with damaged wood (not smooth and cleanable) were identified by the maintenance director. We are in process of completing patching/repairing, it will be completed by the maintenance team on or before March 11th. The interior of all microwaves have been cleaned by the resident coordinator for each home. The dry storage pantries in all homes have been cleaned and organized by resident coordinator. Weekly checks to be done by lead or resident coordinator. The flooring in each outside storage area where reach-in freezers are l”

“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 and Z142 Facility has added additional QA audits for food service and kitchens daily, weekly and monthly. Individual homes will complete daily, weekly and monthly audits, these audits will be reviewed by admin staff each week. Teams will meet weekly to discuss findings and ensure all aspects of the POC are being address appropiately to maintain safe enviroment. OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:”

“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 plan of correction for C240 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: 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 and C455 Refer to plan of correction for C240 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: Refer to plan of correction for C240 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: 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:”

“Based on interview and record review, conducted during a site visit on 10/31/24, the facility's failure to comply with required staffing or staff training practices was substantiated for 1 of 1 sampled staff (#6). Findings include, but are not limited to: Compliance Specialist reviewed training documents for Staff 6 (Universal worker) who was hired on 04/30/24. Records indicated there was no documented training on service plans, orientation to the residents, or documentation showing Staff 6 had successfully demonstrated satisfactory performance in any task assigned in order to work unsupervised. In separate interviews, Staff 1 (ED) stated s/he had started working at the facility in August 2024 and was not aware of staff working without completed training. S/he stated staff were trained on reviewing service plans on their first day. Staff 1 stated Staff 6 was terminated/quit on 06/01/24. Staff 6 reported s/he had started working with residents before having any training and was left alone in the house overnight without anyone to train them. "The next time I went in, there was someone there, but [s/he] left several times during the night for about half an hour at time" and "it made me very uncomfortable with not having any training in case soemthing were to happen to one of the residents". The findings were reviewed with and acknowledged by Staff 1 on 10/31/24. The facility's failure to comply with required staffing or staff training practices was substantiated. Verbal plan of correction: Facility is now doing onboarding. Hiring/interviews are done every Tuesday and if offered a position, onboarding is scheduled right away. Every week on Thursday's LPNs teach medications, transfers, and first aid training. RCC is responsible for completing the competency check off after 3 days of training in the home. Based on interview and record review, conducted during a site visit on 10/31/24, the facility's failure to comply with required staffing or staff training practices was substantiated for 1 of 1 sampled staff (#6). Findings include, but are not limited to: Compliance Specialist reviewed training documents for Staff 6 (Universal worker) who was hired on 04/30/24. Records indicated there was no documented training on service plans, orientation to the residents, or documentation showing Staff 6 had successfully demonstrated satisfactory performance in any task assigned in order to work unsupervised. In separate interviews, Staff 1 (ED) stated s/he had started working at the facility in August 2024 and was not aware of staff working without completed training. S/he stated staff were trained on reviewing service plans on their first day. Staff 1 stated Staff 6 was terminated/quit on 06/01/24. Staff 6 reported s/he had started working with residents before having any training and was left alone in the house overnight without anyone to train them. "The next time I went in, there was someone there, but [s/he] left several times during the night for about half an hour at time" and "it made me very uncomfortable with not having any training in case soemthing were to happen to one of the residents". The findings were reviewed with and acknowledged by Staff 1 on 10/31/24. The facility's failure to comply with required staffing or staff training practices was substantiated. Verbal plan of correction: Facility is now doing onboarding. Hiring/interviews are done every Tuesday and if offered a position, onboarding is scheduled right away. Every week on Thursday's LPNs teach medications, transfers, and first aid training. RCC is responsible for completing the competency check off after 3 days of training in the home.”

“Based on interview and record review, conducted during a site visit on 10/31/24, it was determined the facility failed to have a fully implemented and updated Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated all 89 residents were included in the tool and had a completed ABST evaluation. Not all resident ABST evaluations had been updated at least quarterly in the tool. A review of the ABST indicated the following: · Day shift: Willow 2.17, Redwood 1.93, Cedar 1.24, Birch 2.09, Aspen 1.96, Cascade 1.24, Diamond Peak 1.75, Mt Vernon 0.90, Mt Hood 1.70 staff needed. · Swing shift: Willow 0.12, Redwood 1.40, Cedar 0.91, Birch 0.52, Aspen 1.07, Cascade 0.74, Diamond Peak 1.16, Mt Vernon 0.66, Mt Hood 1.16 staff needed. · Nigh shift: Willow 1.12, Redwood 0.19, Cedar 0.19, Birch 1.10, Aspen 0.24, Cascade 0.35, Diamond Peak 0.66, Mt Vernon 0.16, Mt Hood 0.46 staff needed. A review of the posted staffing plan and staffing schedules for 09/25/24 through 10/31/24 indicated the following: · Day shift: two universal workers (for each home) · Swing shift: two universal workers, one lead direct care staff (for each home) · Night shift: one universal worker (for each home) · The facility was not staffing per the posted staffing plan and tool. · The facility had six residents requiring two-person assistance with transferring, rolling, or sit to stand and was only scheduling one staff in each home on night shift for Cedar, Diamond, Redwood, and Willow homes. In an interview on 10/31/24, Staff 1 (Executive Director) stated the following: · The facility was using the state ABST. · The tool generated a 24-hour staffing plan. · The tool was updated with service plan updates, new move-ins, and change of condition. · The facility had floats and shift supervisors that could go around between the nine homes. · The facility was calculating their ABST hours by dividing by twelve hours or taking an average, even though they had staff working eight hours and 4 hour shifts as well. Findings were reviewed with and acknowledged by Staff 1 during phone call on 11/05/24. It was confirmed the facility failed to have a fully implemented and updated ABST. Based on interview and record review, conducted during a site visit on 10/31/24, it was determined the facility failed to have a fully implemented and updated Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated all 89 residents were included in the tool and had a completed ABST evaluation. Not all resident ABST evaluations had been updated at least quarterly in the tool. A review of the ABST indicated the following: · Day shift: Willow 2.17, Redwood 1.93, Cedar 1.24, Birch 2.09, Aspen 1.96, Cascade 1.24, Diamond Peak 1.75, Mt Vernon 0.90, Mt Hood 1.70 staff needed. · Swing shift: Willow 0.12, Redwood 1.40, Cedar 0.91, Birch 0.52, Aspen 1.07, Cascade 0.74, Diamond Peak 1.16, Mt Vernon 0.66, Mt Hood 1.16 staff needed. · Nigh shift: Willow 1.12, Redwood 0.19, Cedar 0.19, Birch 1.10, Aspen 0.24, Cascade 0.35, Diamond Peak 0.66, Mt Vernon 0.16, Mt Hood 0.46 staff needed. A review of the posted staffing plan and staffing schedules for 09/25/24 through 10/31/24 indicated the following: · Day shift: two universal workers (for each home) · Swing shift: two universal workers, one lead direct care staff (for each home) · Night shift: one universal worker (for each home) · The facility was not staffing per the posted staffing plan and tool. · The facility had six residents requiring two-person assistance with transferring, rolling, or sit to stand and was only scheduling one staff in each home on night shift for Cedar, Diamond, Redwood, and Willow homes. In an interview on 10/31/24, Staff 1 (Executive Director) stated the following: · The facility was using the state ABST. · The tool generated a 24-hour staffing plan. · The tool was updated with service plan updates, new move-ins, and change of condition. · The facility had floats and shift supervisors that could go around between the nine homes. · The facility was calculating their ABST hours by dividing by twelve hours or taking an average, even though they had staff working eight hours and 4 hour shifts as well. Findings were reviewed with and acknowledged by Staff 1 during phone call on 11/05/24. It was confirmed the facility failed to have a fully implemented and updated ABST.”

“Based on interview and record review, conducted during a site visit on 10/31/24, it was determined the facility failed to have a fully implemented and updated Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated all 89 residents were included in the tool and had a completed ABST evaluation. Not all resident ABST evaluations had been updated at least quarterly in the tool. A review of the ABST indicated the following: · Day shift: Willow 2.17, Redwood 1.93, Cedar 1.24, Birch 2.09, Aspen 1.96, Cascade 1.24, Diamond Peak 1.75, Mt Vernon 0.90, Mt Hood 1.70 staff needed. · Swing shift: Willow 0.12, Redwood 1.40, Cedar 0.91, Birch 0.52, Aspen 1.07, Cascade 0.74, Diamond Peak 1.16, Mt Vernon 0.66, Mt Hood 1.16 staff needed. · Nigh shift: Willow 1.12, Redwood 0.19, Cedar 0.19, Birch 1.10, Aspen 0.24, Cascade 0.35, Diamond Peak 0.66, Mt Vernon 0.16, Mt Hood 0.46 staff needed. A review of the posted staffing plan and staffing schedules for 09/25/24 through 10/31/24 indicated the following: · Day shift: two universal workers (for each home) · Swing shift: two universal workers, one lead direct care staff (for each home) · Night shift: one universal worker (for each home) · The facility was not staffing per the posted staffing plan and tool. · The facility had six residents requiring two-person assistance with transferring, rolling, or sit to stand and was only scheduling one staff in each home on night shift for Cedar, Diamond, Redwood, and Willow homes. In an interview on 10/31/24, Staff 1 (Executive Director) stated the following: · The facility was using the state ABST. · The tool generated a 24-hour staffing plan. · The tool was updated with service plan updates, new move-ins, and change of condition. · The facility had floats and shift supervisors that could go around between the nine homes. · The facility was calculating their ABST hours by dividing by twelve hours or taking an average, even though they had staff working eight hours and 4 hour shifts as well. Findings were reviewed with and acknowledged by Staff 1 during phone call on 11/05/24. It was confirmed the facility failed to have a fully implemented and updated ABST. Based on interview and record review, conducted during a site visit on 10/31/24, it was determined the facility failed to have a fully implemented and updated Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated all 89 residents were included in the tool and had a completed ABST evaluation. Not all resident ABST evaluations had been updated at least quarterly in the tool. A review of the ABST indicated the following: · Day shift: Willow 2.17, Redwood 1.93, Cedar 1.24, Birch 2.09, Aspen 1.96, Cascade 1.24, Diamond Peak 1.75, Mt Vernon 0.90, Mt Hood 1.70 staff needed. · Swing shift: Willow 0.12, Redwood 1.40, Cedar 0.91, Birch 0.52, Aspen 1.07, Cascade 0.74, Diamond Peak 1.16, Mt Vernon 0.66, Mt Hood 1.16 staff needed. · Nigh shift: Willow 1.12, Redwood 0.19, Cedar 0.19, Birch 1.10, Aspen 0.24, Cascade 0.35, Diamond Peak 0.66, Mt Vernon 0.16, Mt Hood 0.46 staff needed. A review of the posted staffing plan and staffing schedules for 09/25/24 through 10/31/24 indicated the following: · Day shift: two universal workers (for each home) · Swing shift: two universal workers, one lead direct care staff (for each home) · Night shift: one universal worker (for each home) · The facility was not staffing per the posted staffing plan and tool. · The facility had six residents requiring two-person assistance with transferring, rolling, or sit to stand and was only scheduling one staff in each home on night shift for Cedar, Diamond, Redwood, and Willow homes. In an interview on 10/31/24, Staff 1 (Executive Director) stated the following: · The facility was using the state ABST. · The tool generated a 24-hour staffing plan. · The tool was updated with service plan updates, new move-ins, and change of condition. · The facility had floats and shift supervisors that could go around between the nine homes. · The facility was calculating their ABST hours by dividing by twelve hours or taking an average, even though they had staff working eight hours and 4 hour shifts as well. Findings were reviewed with and acknowledged by Staff 1 during phone call on 11/05/24. It was confirmed the facility failed to have a fully implemented and updated ABST.”

“The findings of the kitchen inspection, conducted 09/27/23, 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 kitchen inspection, conducted 09/27/23, 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 revisit to the kitchen inspection of 09/27/23, conducted 01/26/24, 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. The findings of the revisit to the kitchen inspection of 09/27/23, conducted 01/26/24, 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. include, but are not limited to: Observation of the six cottage kitchens and facility food storage areas on 9/27/23 at 11:00 am am through 3:30 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: * Interior of reach in refrigerators and freezers; * Hand held can openers; * White shelving in main food storage area; * Fan next to walk in cooler; * Interior and exterior of kitchen drawers, cupboards and cabinets; * In between range and counter tops; * Interior of ovens; * Interior of microwaves; and * Floors in storage areas where reach in freezers located. b. The following areas were found in need of repair: * Multiple drawers or cupboards with damaged wood (not smooth/cleanable); * Metal shelves in main food storage area rusted and corroded; * Holes under sinks in kitchenette; and * Multiple pots/pans/bowls, etc., heavily scored or peeling protective coating. c. Multiple cutting boards were found damaged and in poor repair. d. Multiple potentially hazardous food items were found not labeled or dated. e. Facility was not using pasteurized eggs for undercooked egg foods like poached or soft-fried eggs. f. Potentially hazardous foods stored incorrectly found next to or above ready-to-eat foods. g. Scoops were found stored in bulk food item bins and ice bin. h. Clean dishes were observed stored next to hand washing/prep sink without protection from potential splash contamination while drying. These dishes were also sitting next to a crock pot of food during lunch service. i. Direct care staff not able to state the correct reheating and/or cook-to temperatures for food items. j. Individual house pets were having their food bowls stored in kitchens with food left in bowls, posing a potential attractant for pests. Facility pets should be kept out of food preparation and serving areas as best as possible to avoid potential contamination of food, food preparation areas and equipment. k. Multiple direct care staff who were responsible for ensuring dishes were cleaned and sanitized were not using the identified correct cycle for sanitizing of dishes. Per interview with maintenance, the cycle that would sanitize and that staff are to be using was the heavy-duty cycle. Five of six houses were using the normal/short cycle. The facility did not have a current system in place to validate that the dishwashers were effectively sanitizing dishes. l. The facility did not have a system in place to ensure the ice makers in the house/unit freezers and water filters were cleaned and maintained per manufacturer's recommendations to ensure ice was safe to consume. Staff 17 (Maintenance Coordinator) was interviewed and acknowledged he had not changed the filters or cleaned the ice makers, and he did not know when they were last done. Surveyor reviewed above areas with Staff 2 (Food and Supply Lead/PIC) and s/he acknowledged the identified areas.  At approximately 3:00 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Executive Director). S/he acknowledged the identified areas. 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. include, but are not limited to: Observation of the six cottage kitchens and facility food storage areas on 9/27/23 at 11:00 am am through 3:30 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: * Interior of reach in refrigerators and freezers; * Hand held can openers; * White shelving in main food storage area; * Fan next to walk in cooler; * Interior and exterior of kitchen drawers, cupboards and cabinets; * In between range and counter tops; * Interior of ovens; * Interior of microwaves; and * Floors in storage areas where reach in freezers located. b. The following areas were found in need of repair: * Multiple drawers or cupboards with damaged wood (not smooth/cleanable); * Metal shelves in main food storage area rusted and corroded; * Holes under sinks in kitchenette; and * Multiple pots/pans/bowls, etc., heavily scored or peeling protective coating. c. Multiple cutting boards were found damaged and in poor repair. d. Multiple potentially hazardous food items were found not labeled or dated. e. Facility was not using pasteurized eggs for undercooked egg foods like poached or soft-fried eggs. f. Potentially hazardous foods stored incorrectly found next to or above ready-to-eat foods. g. Scoops were found stored in bulk food item bins and ice bin. h. Clean dishes were observed stored next to hand washing/prep sink without protection from potential splash contamination while drying. These dishes were also sitting next to a crock pot of food during lunch service. i. Direct care staff not able to state the correct reheating and/or cook-to temperatures for food items. j. Individual house pets were having their food bowls stored in kitchens with food left in bowls, posing a potential attractant for pests. Facility pets should be kept out of food preparation and serving areas as best as possible to avoid potential contamination of food, food preparation areas and equipment. k. Multiple direct care staff who were responsible for ensuring dishes were cleaned and sanitized were not using the identified correct cycle for sanitizing of dishes. Per interview with maintenance, the cycle that would sanitize and that staff are to be using was the heavy-duty cycle. Five of six houses were using the normal/short cycle. The facility did not have a current system in place to validate that the dishwashers were effectively sanitizing dishes. l. The facility did not have a system in place to ensure the ice makers in the house/unit freezers and water filters were cleaned and maintained per manufacturer's recommendations to ensure ice was safe to consume. Staff 17 (Maintenance Coordinator) was interviewed and acknowledged he had not changed the filters or cleaned the ice makers, and he did not know when they were last done. Surveyor reviewed above areas with Staff 2 (Food and Supply Lead/PIC) and s/he acknowledged the identified areas.  At approximately 3:00 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Executive Director). S/he acknowledged the identified areas. Plan of Correction: 1- On 10/2/2023, rounds to each of the 9 homes was completed by the Administrator and Maintenance Coordinator to identify cleaning and repair needs. During these rounds the following was addressed or is in process of being addressed: a-Each reach-in refrigerator and freezer has been cleaned by the Resident Coordinator for each home. b-Every handheld can opener was inspected by the Administrator. Damaged can openers were discarded and replaced with new ones. Dirty can openers were cleaned by the Resident Coordinator for each home. c-The white shelving in the main food storage area was replaced and the fan next to the walk in cooler in the main food storage area was deep cleaned by the Food and Supply Coordinator. Weekly cleaning of all fans and shelving was added to the Food/supply chore list on 10/9/2023. d-The interior of all ovens and microwaves have been cleaned by the Resident Coordinator for the home. e-The inter”

“Based on record review and interview, it was determined the facility failed to ensure 13 of 39 staff reviewed who prepare and serve food had active food handler's certificates (#s 4 thru 16). Findings include, but are not limited to: On 09/27/23 at approximately 2:30 pm, surveyor reviewed employee records for active food handler's cards. There were 10 employees who did not have a food handler's card on file and three that were found to be expired. At 2 pm, Staff 1 (Executive Director) verified there were multiple staff that did not have active food handler's certification. Staff 1 verified that those staff duties did include preparing food to residents. Based on record review and interview, it was determined the facility failed to ensure 13 of 39 staff reviewed who prepare and serve food had active food handler's certificates (#s 4 thru 16). Findings include, but are not limited to: On 09/27/23 at approximately 2:30 pm, surveyor reviewed employee records for active food handler's cards. There were 10 employees who did not have a food handler's card on file and three that were found to be expired. At 2 pm, Staff 1 (Executive Director) verified there were multiple staff that did not have active food handler's certification. Staff 1 verified that those staff duties did include preparing food to residents. Plan of Correction: 1- On 9/28/2023, an audit of all current employees was completed by the HR Coordinator to identify which employees needed a current Food handlers card. This list was was then given to the Staffing Coordinator who called each employee on 9/28/2023. By 9/29/2023, every employee had a current card on file. 2- To prevent reoccurrence, the HR Coordinator will now complete a company-wide audit every two weeks to identify employees who are needing their cards renewed or close to needing their cards renewed. After that audit, the HR team will communicate with the employees and track the progress until the new/updated card is received. The HR team and the Administrator will meet weekly to discuss the audit, who was identified as needing documentation, and the plan/progress on obtaining the cards. 3- The Administrator will be responsible to ensure the corrections are completed and monitored. Plan of Correction: 1- On 9/28/2023, an audit of all current employees was completed by the HR Coordinator to identify which employees needed a current Food handlers card. This list was was then given to the Staffing Coordinator who called each employee on 9/28/2023. By 9/29/2023, every employee had a current card on file. 2- To prevent reoccurrence, the HR Coordinator will now complete a company-wide audit every two weeks to identify employees who are needing their cards renewed or close to needing their cards renewed. After that audit, the HR team will communicate with the employees and track the progress until the new/updated card is received. The HR team and the Administrator will meet weekly to discuss the audit, who was identified as needing documentation, and the plan/progress on obtaining the cards. 3- The Administrator will be responsible to ensure the corrections are completed and monitored. There are no detail notes for this visit.”

“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 C240. Refer to C370. 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 C240. Refer to C370. Refer to plan of correction for C240 and C370. Refer to plan of correction for C240 and C370. There are no detail notes for this visit.”