The findings of the kitchen inspection, conducted 05/09/24, 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 05/09/24, conducted 07/18/24, 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 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 kitchen and unit kitchenettes were reviewed on 05/09/24 from 11:30 am through 3:00 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:

* Popcorn machine interior and kettle;

* Maple and oak kitchenette drawers/cupboards;

* Maple and oak kitchenette ovens and range top burners;

* Kitchen drains;

* Areas of ceiling in main kitchen;

* Kitchen ceiling vents/light fixtures;

* Countertop mixer; and

* Exterior of meal delivery carts.

b. The following areas were in need of repair:

* Main kitchen ceiling with peeling/chipped paint;

* Drawers in units with exposed porous wood; and

* Wood shelving under steam table with exposed porous wood.

c. Interview with Staff 2 (Person in Charge) revealed inadequate knowledge in employee illnesses/symptoms that required exclusion. Staff 2 was not able to correctly identify all protein cook to temperatures. Staff 2 was not able to correctly discuss proper cooling processes.

d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. Multiple grill spatulas were found with handles damaged and no longer smooth cleanable surfaces and in need of replacement. Utility cart storing chemicals was rusted and non smooth/cleanable surface.

e. Multiple food items in reach in fridges and freezers did not contain open dates or use by dates. One item in unit fridge was found past it's identified use by date (sliced cheese use by date: 5/7/24).

f. Oak unit refrigerator did not have a thermometer to monitor cold food storage temperatures. Both Oak and Maple unit refrigerators storing resident food and drinks containing potentially hazardous food items did not have process where cold food temps were monitored by facility staff to ensure food items held at 41 degrees or below as required. Staff 1 (Executive Director) verified there was no current process to monitor the refrigerator temperatures.

h. Maple kitchenette had single service items (spoons/straws) that were stored open to potential contamination with food contact surfaces exposed.

i. Staff 2 was observed washing dishes. Staff 2 did not undergo a hand wash step when going between washing dirty dishes to handling clean dishes. Staff 2 was also observed wiping clean sanitized dishes with a towel on the food contact surfaces to help them dry. This towel used to wipe the sanitized dishes was placed on the waist of Staff 2 and was exposed to potential dirty spray while washing dishes.  

At approximately 2:00 pm and 2:45 pm, surveyors reviewed above areas with Staff 2 (Dining Services Director), Staff 3 (Maintenance Director) and Staff 1 (Executive Director), who acknowledged the identified areas.

Providers plan of correction for the tag of C240 and memory care tag Z142 is as follows.

A. Food debris, splatters, loose food, trash, dirt, dust and or black matter that was visable on the following areas has been cleaned and made in good repair.

~The popcorn machine has been cleaned and stored in an offsight location at this time.

~Maple and Oak kitchenette drawers and cupbaords have been wiped down and food debris removed. This task has been added to the nightly cleaning list for  care partners to complete nightly. This will be over seen each night by the supervisor on duty.

~Maple and Oak kitchenette ovens and burners are to have debris removed and cleaned nightly as needed to remove food debris and spills. This task has been added to the nightly cleaning task list and will be over seen nightly by the supervisor on duty.

~Kitchen drains have been cleaned and task added to weekly zonal cleaning for the kitchen cleaning. This will be monitored by the Dining Serviced Director.

~Areas in kitchen ceiling in main kitchen have been cleaned and patched and repainted. Cleaning of kitchen ceiling will be done monthly by maintenance director.

~Kitchen ceiling vents and light fixtures were taken down and cleaned and repainted. Maintenance director will check and clean monthly.

~Countertop mixer has been deep cleaned with food debris removed. A plastic dust cover was purchased and is in place while not in use to keep dust off the machine. Cleaning of this item has been added to the weekly zonal cleaning for this item. This will be overseen by the Dining Services Manager.

~Exterior of meal delivery cart was deep cleaned and debris was removed. This task has been added to the daily cleaning task list for the kitchen and will be overseen by the Dining Services Director.

B.The following areas were in need of repair.

~Main Kitchen ceiling had peeling and chipped paint. The areas have been cleaned, sealed and repainted. Maintenance Director will observe ceiling monthly and repair any further areas as needed.

~Drawers in units with exposed porus wood and wood shelving under steam table has porus wood. This area has been repainted and a metal overlay has been ordered to prevent continued surface areas from being scraped, scratched and wood exposed as a porus surface. This metal is expected to be in the community 6/25/2024 and will be installed within 2 weeks after the metals arrives. This area will be inspected monhly to look for areas that have non cleanable surfaces by the Dining Services Director.

C. Staff person was unable to demonstrate adaquate knowledge of employee illness and symptoms for exclusion. This director has printed the illness policy and each kitchen employee was given a copy and a signed copy was placed in each kitchen persons file. A copy of the illness policy was also made available in the kitchen area to reference. This policy is also available in the community guidebook.

D. Multiple cutting boards and cutting surfaces were found heavily stained. New Cutting boards were ordered and are in place in the kitchen. Old stained cutting boards have been removed from the community. Dining Services Manager will inspect items monthly and order new items as these become stained or not have a cleanable surface area.  

~Multiple grill spatulas were damaged and no longer had smooth cleanable surfaces. These items were removed from the kitchen and replaced with brand new spatulas. Dining Services Manager will inspect items monthly or as needed and replace or repair items when surface no longer cleanable or become porus.

~utility cart that was storing chemicals was rusted and not a smooth cleanable surface. Cart was removed from the premises and chemicals are now stored in a different location.

E. Multiple food items in fridges and freezers did not contain open or use by dates. The task of dating items will be done as items are opened and used. It will be overseen each day by the cook on duty.

F. Oak and Maple fridges did not have cold food thermometers where food temps could be monitored daily. Fridge thermometers were purchased for both fridges and are in place in each fridge. The task of monitoring the temps was placed in the ECP system and will be done daily by the med techs.

H. Maple kitchenette had single serve spoons and straws that were stored open. Straw and spoon dispensers were purchased and are in place in both kitchenettes. These items will be replaced as needed.

I. Staff was observed washing dishes and not washing hands when going between dirty and clean dishes. The staff was also observed using a dish towel to wipe the surface of a sanitized dish after it had been on the waist of a staff member. Kitchen inservice has been scheduled for June 25th and the topic of proper sanitation and dish washing will be taught again. The regional Dining Services Director will oversee this class.

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 C 240.

see C 240