Desire For Healing Inc

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

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 Temps - all staff have been reminded/instructed to temp the Memory Care food just prior to transport to Memory Care. (8/14/25) Memory Care carestaff also reminded/instructed to temp the last food tray served in Memory Care and record temp. If food is below acceptable temperature, the plate may be microwaved for 30 seconds (microwave in Memory Care). (8/14/25) A 50-70 plate plate warmer has been ordered from Direct Supply to warm plates prior to dishing out food to ensure that hot meals are at temp when serving to both Memory Care and RCF residents. (delivery of plate warmer expected 8/22/25)

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

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.

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.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 10/05/22, the operation of the dish machine was observed. The dish machine utilized a low temperature rinse cycle with chlorine to sanitize dishes. The sanitizer was tested with the available strips and the chemical level was noted below the required range. There was no documented evidence of monitoring of the sanitizing solution. The sanitizer solution bottle was observed to be empty. Staff 2 (Dietary Manager) replaced the empty bottle of sanitizer. The dish machine did not reach the required temperature of 120 degrees Fahrenheit. A fan located in the dish machine area was noted with dust and debris on the cage blowing into the kitchen. During observation of meal service, staff did not change gloves between tasks and were touching ready to eat foods. Staff were noted to not remove gloves when entering the kitchen. Hand hygiene and the areas in the kitchen needing cleaning and repair were observed and reviewed with Staff 1 (Executive Director) and Staff 2 on 10/05/22. They acknowledged the findings.

1. Tag C 240 requires policy & procedure updating and enforment to correct staff actions and monitoring, and an outside professional plumbing company to address the mechanical issues of the plumbing system and dish sanitizing machine. 2. The kitchen policies & procedures will be updated and enforced to routinely test temperature and sanitation chlorine levels and log approprietly, and to check the sanitizer solution bottle for adequate solution. The stand-alone fan was removed from the kitchen. The plumbing company will fix the low water pressure that was causing the dish machine to underperform both in reaching the required operating temperature and in distributing the chlorine used to sanitize the dishes. The kitchen dish machine temperature and sanitation logs will be monitored by the Food Services Manager. Kitchen staff will be montiored by the Food Services Manager, Administrator, Assistant Administrator, Infection Prevention Control Manager, or Clinical staff during meals to ensure glove change and hand sanitation procedures are being adhered to. 3. Kitchen logs of sanitzer temperature and chlorine potency for the dish sanitizer will be monitored at least weekly.  Hand hygiene (washing and glove changing) will be monitored periodically throughout each week to instill proper hand hygiene and glove changing practice. 4. The Food Service Manger and the Executive Administrator will be responsible for seeing that all corrections are completed. The Food Services Manager will continue with ongoing monitoring of these corrections to prevent the issues from reoccurring.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room. Observations of staff during the survey on 10/05/22 revealed multiple staff failed to wear medical face mask, wear masks correctly, or wore no face mask at all. The need to ensure staff consistently wore a medical face mask was reviewed with Staff 1 (Executive Director). She acknowledged the findings.

1. All staff will wear protective procedural masks at all times except when in a room alone. 2. Masking procedures will be reiterated at the All Employee Meetings each month to re-inforce the mandate to all employees. These meetings occur the last Wednesday of each month. Monitoring will be ongoing and proper instruction of wearing the masks will be given as needed. 3. The proper wearing of masks will be evaluated nearly continuously since the masking mandate calls for nearly consistant wearing of the masks. The Infection Prevention Control Specialist will inform management and staff when any changes occur to the masking and/or face shielding mandated guidelines by OHA SOQ and/or CDC. 4. The Executive Administrator, Infection Prevention Control Specialist, Assistant Administrator, and RCC will continually monitor all staff for proper masking (and face shield if/when necessary) to control the spread of COVID-19.

The findings of the kitchen inspection, conducted 10/05/22, 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 10/05/22, conducted 12/13/22, 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.