Avamere at Sandy Assisted Living Facility

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. Findings include, but are not limited to: Observations of the primary kitchen and assisted living dining room on 07/20/23 from 10:50 am through 1:02 pm identified the following: a. An accumulation of food spills, splatters, loose food, dirt, and dust on or underneath the following: * Upright refrigerator (near the entrance of the kitchen) had yellow colored liquid spilled on the lower shelf; * Southbend oven had an accumulation of food matter buildup on the inside of the oven; * Floor fan had a buildup of dirt and dust debris that was blowing directly on clean dishes; * Metal storage rack (near the warewash machine) that stored clean dishes had a buildup of dirt and dust debris; and * Dining room drink counter cabinet (underneath the sink) had an accumulation of brown matter. b. The following areas were found in need of repair: * Montague Grizzly oven was not operable; * Grill next to the oven was not operable; * Walk-in freezer door had missing piece of gasket which caused ice buildup around the freezer door; and * Dining room drink counter cabinet doors had broken wood veneer creating an uncleanable surface. c. Observation and temperature audit of the cold food items on the salad bar (located in the dining room) identified the temperature of cottage cheese was 48 degrees F. (above the required cold temperature zone of 41 degrees F. or below). d. All staff working in the kitchen failed to have documented evidence of valid Oregon Food Handler cards. The kitchen was toured and the need to ensure the kitchen was maintained in accordance with Oregon food sanitation rules was discussed with Staff 1 (Director of Quality and Compliance) and Staff 2 (Director of Culinary Services) at 1:02 pm. They acknowledged the above findings.

C240 a. 1) Facility staff immediately did a deep clean of all kitchen and dining room areas including but not limited to all areas noted in the SOD.   2) Plan of correction includes a Dietary Audit Sheet to be completed daily by dietary staff.  If an items needs to be referred to maintenance or housekeeping for deeper cleaning, a referral will be made through the maintenance workflow system, TELS with follow up by the Dietary Services Manager.  Inservice with all relevant employees completed on cleaning and sanitation protocols.  Protocols all posted in the kitchen area for reference. 3) Dietary Service Manager will audit weekly and provide additional inservice and training as needed. 4) Executive Director is responsible to see that the corrections are completed and monitored. b. 1) Non-functioning Montague Grizzly oven and grill were removed from the kitchen. Gasket for freezer is on order.  Follow up email sent to vendor for estimated delivery date. Work order placed with maintenance for cabinet veneer door replacement.   2) Plan of correction includes weekly walkthrough between DSM, Maintenance Director and ED and any areas of improvement needed, will be placed on a workorder for repair and/or removal. 3) Weekly walkthroughs will be completed. 4) Executive Director is responsible to see that the corrections are completed and monitored. c. 1) Plan of correction includes salad bar food temperature readings on three different foods, during meal service. Documentation on temperature log kept in the kitchen by either the salad bar attendant or cook.  Inservice on process completed and documented. 2) Monitoring and documentation of temperatures completed daily by salad bar attendant or cook. 3) Dietary Services Manager will review logs weekly and spot check temperatures periodically. 4) Executive Director is responsible to see that the corrections are completed and monitored. d. 1) DSM immediately reached out to all kitchen staff to get copies of all Food Handler cards, that were not found in the personel files.  All are current and up to date. 2) Plan of correction includes audits conducted of certifications for all new hires and renewals for exisiting employees, using the training grid. 3) Review training grid and certifications at monthly CQI meeting. 4) Executive Director is responsible to see that the corrections are completed and monitored.

The findings of the kitchen inspection, conducted 07/20/23, 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 first revisit to the kitchen inspection of 07/20/23, conducted 09/22/23, 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.

Based on interview and record review it was confirmed that facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include but not limited to: During an unannounced site visit on 10/13/2022, Compliance Specialist (CS) interviewed Staff #1 (S1) who reported: *Facility had a large outbreak of COVID in April and  May 2022 including 18 staff and 18 residents. *Scheduling was very difficult at that time, and there was a lot of piecing schedules together *S 1 was unable remember details of phone conversations with Staff #4 (S 4) from 4/28/2022 but stated they could not allow one med tech who was COVID + to go home without having another med tech come in to replace them. The facility was unable to provide documentation of an exception granted by the public health department to have COVID + staff working on 4/28/2022. A review of the facility's COVID case log revealed that (S4) tested + on 4/28/2022. A review of facility time cards revealed that S4 worked the following shifts: 4/27/2022: 10:50am-10:14pm 4/28/2022: 5:45am-10:20am, 9:45pm-4:20am A review of facility's COVID screening logs for 4/27/2022-4/29/2022 revealed that S4 did not complete a COVID screening for any of those shifts. These findings were reviewed with and acknowledged by S1 by phone on 10/19/2022.