Citation #1: C0240 - Resident Services Meals, Food Sanitation Rule
Visit History:
t Visit: 8/11/2025 | Not Corrected
1 Visit: 10/28/2025 | Not Corrected
Regulation:
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).
Inspection Findings:
Based on observation, record review 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 facility main kitchen areas were reviewed on 08/11/25 from 09:30 am through 2:00 pm and found the following:
a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:
* Ceiling vent above steam table
* Multiple sprinkler heads and/or smoke detectors
* Floor edges, corners under major equipment
* Side of grill
* Side of fryer
* Wall beside fryer
* Commercial toaster
* Interior of microwave
* Area directly under grill but above oven
* Knobs of oven, grill, stove
* Interior of ovens
* Stainless steel shelving
* Shelving storing spices
b. The following areas were found in need of repair:
* Reach in cooler by line not holding correct cold food storage temperature
* Microwave interior with sections chipped/cracked yielding non smooth surfaces
* Sections of caulking on service side of steam table missing/cracked
* Sections of caulking by three compartment sink missing/cracked/needing repaired
c. Multiple pans and/or pots were observed with heavy carbon deposits and/or grease/baked on cooked on food debris on exterior and food contact surfaces. Multiple non stick fry pans were observed with the protective coating scratched off and in need of replacement.
d. Dishwashing staff did not have hair restrained when handling clean/sanitized equipment. Service staff observed to not have hair effectively retrained and hair touching table top/plates on tables during meal service.
e. Kitchen staff observed over loading dishwashing racks where multiple cooking pans were not positioned so that all areas of the pan could be touched by sanitizing agents in the wash/rinse cycles as required. Multiple dishwashing racks were observed stored on the floor when not in use.
f. Kitchen staff did not wash or sanitize hands on multiple occasions after handling dirty dishes, touching their face/glasses or touching potentially contaminated ares/equipment before handling clean/sanitized dishes.
g. Kitchen did not have a small diameter thermometer as required.
h. Staff were touching ready to eat items with gloved hands that had been potential contaminated from other tasks. Staff was observed to leave the line and enter the walk-in cooler touching the handle of the walk in multiple times. The staff member then prepared ready to eat (RTE) items such as sandwiches, salads, burger buns and relish plates. Single use gloves are to be used when handling RTE items.
i. Staff was observed to serve multiple burgers without checking the temperature prior to service to residents. Staff 2 (Executive Chef) was interviewed and confirmed they were using a “fully cooked” product that came in frozen. Staff 2 verified the facility did not check the temperature of the product before service. When asked about the preparation process it was discussed that the facility warmed the frozen product in the microwave for 2-3 minutes then fried the product for an additional 3-5 minutes. Staff 2 was not aware of the manufactures recommended reheat temperatures to ensure product would be safe for consumption. Staff 2 was not able to demonstrate the temperature that the current process would produce the burgers at to ensure was served at palatable temperatures or appropriate hot holding temperatures.
j. The reach in refrigerator next to the steam line was observed at 50 degrees. Multiple potentially hazardous food items were found stored in the refrigerator. A few minutes later after all items were removed the fridge it was found at 48 degrees. Logs were reviewed and there were 14 of 28 entries where the fridge was noted at above 41 degrees. The reading for 08/10 am was noted at 54 degrees, and 40 degrees at dinner meal that day. No reading was recorded for 08/11 breakfast. Staff 2 acknowledged there had been issues with that refrigerator. They were aware of the issues the previous day and had removed the items and placed in ice baths and or discarded if needed when the temperature of the refrigerator was outside parameters. Staff 2 indicated the temperature was at acceptable levels after dinner the night before. Staff 2 acknowledged it was above acceptable cold holding temperatures at the time of survey and discarded food items in the fridge. Staff 2 acknowledged the refrigerator was not correctly holding temperatures and would contact a vendor to evaluate it. Staff 2 verified food items would not be stored in the unit until it was operating correctly.
k. Multiple items were found stored in walk in cooler and reach in cooler by steam line not dated when opened or prepared. One item (Tuna salad) was dated as prepared on 08/04 and was not discarded by 08/10 (seven days) as required. Staff 2 discarded the tuna salad.
l. Kitchen staff was observed to check temperature of baked chicken. Staff was not observed to sanitize the thermometer prior to checking temperature. First pan of check did not read at 165 degrees or greater and was placed back in the oven to finish cooking. Second pan of chicken temperature was checked and was found greater than 165 degrees, however kitchen staff did not sanitize the thermometer after checking the temperature of the first pan of chicken therefor potentially contaminating the second pan of chicken.
At approximately 12:45, surveyor reviewed identified areas with Staff 2 who acknowledged areas needed correction. At 1:30 pm the surveyor reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Executive Director) who voiced understanding of areas needing correction.
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).
This Rule is not met as evidenced by:
Plan of Correction:
a.
1.The dust on the ceiling vent was cleaned on 08.11.2025 at time of survey. Sprinkler heads are cleaned every 6 months, with last visit in February, and were due in August. They were cleaned on 08.15.2025 as planned. The following areas have been thoroughly cleaned to be in sanitary manner: floor edges, corners under major equipment, side of grill, side of fryer, wall beside fryer, interior of microwave, area directly under grill but above oven, all effected knobs, interior of ovens, stainless steel shelving, shelving storing spices, juice machine in memory care. The toaster was replaced.
2.,3., and 4. Daily/ Weekly/ Monthly cleaning checklists implemented to clean these areas that include staff sign off that they thoroughly cleaned these areas. Checklists will then get turned into Dining Services Director who will ensure completion and compliance. Dining Services Director will then turn in these cleaning checklists to GM who will walk through and ensure completion and compliance as well.
b.
1. Reach in cooler not in use until this is repaired no later than the alleged compliance date. New microwave ordered and in use. Sections of caulking on serving side of steam table, 3 compartment sink, and behind sink in kitchenette repaired.
2. Staff training done to include reporting these concerns through work order system to ensure resolution. Dining Services Director and GM will walk through weekly to ensure these areas of repair are put in as work orders and then resolved appropriately.
3. and 4. This will be evaluated weekly by walking through by GM and Dining Services Director who will also ensure completion and monitoring.
c.
1. All effected pans were discarded and replaced.
2., 3., and 4. Dining Services Director will ensure that his team will not be using pans or items in this condition. He will audit this monthly to ensure compliance. GM will evaluate, walk through, and audit monthly to ensure compliance, correction, and ongoing monitoring.
d.
1. Training performed with dishwasher and service staff to restrain hair. Dishwasher and service staff now restrain hair accordingly.
2. Training was performed to correct immediately. Dining Services Manager and/or cook will ensure this is done daily.
3. and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored.
e.
1. Kitchen staff re-trained to ensure that racks are not overloaded nor overlapping to ensure proper sanitization in wash/rinse cycles. Additional training included to never set racks on kitchen floor. This GM and Dining Services Director have since viewed/evaluated to ensure compliance.
2., 3., and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored.
f.
1. Inservice was completed for handwashing after handling dirty items, before touching clean items.
2., 3., and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored.
h.
1. This was corrected immediately and directly after it occurred in front of surveyor. All kitchen/dining team in-service to be held within compliance date to ensure no future errors by staff.
2., 3., and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored.
i.
1. and 2. These cooked hamburgers will be temped moving forward each time one is served to ensure service at a palatable temperature and appropriate hot holding temperature.
3. and 4. Cooks will be responsible for temping these each time. Dining Services Director will ensure compliance from the cooks to ensure completion and ongoing monitoring. GM will evaluate and ensure ongoing compliance by auditing weekly.
j.
1. and 2. Reach in cooler not in use currently and will not use until repair occurs. In-service to be done within compliance date to ensure we get temperatures within compliance and if not, then we need to stop use and contact vendor immediately for repair. Once repaired, we can then resume use.
3. and 4. This will be evaluated to ensure ongoing compliance and monitoring by the Dining Services Director weekly and then by the GM monthly.
k.
1. and 2. Inservice completed to ensure staff are properly dating items upon opening or repair and then discarded appropriately. Observed and audited to ensure compliance.
3. and 4. This will be evaluated to ensure ongoing compliance and monitoring by the Dining Services Director weekly and then by the GM monthly.
l.
1. and 2. Inservice completed to ensure sanitization of thermometer before and after temping foods. Observed staff to ensure compliance.
3. and 4. This will be evaluated each day the Dining Services Director is working and weekly by the GM as both the GM and Dining Services Director will be responsible to ensure this is corrected ongoing and monitored.
m.
1. and 2. Protective aprons were purchased and are in use during meal service. Inservice completed to ensure expectations.
3. and 4. This will be evaluated to ensure ongoing compliance and monitoring by the Memory Care Administrator each day she is working, Dining Services Director weekly, and then by the GM monthly.