The findings of the kitchen inspection, conducted 01/04/24, 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 01/04/24, conducted on 03/13/24, 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 was reviewed on 01/04/24 from 11:15 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:

* Refrigerators in unit kitchenettes;

* Floors, walls, cabinets and drawers in unit kitchenettes;

* Handles of reach in coolers and freezers in main kitchen area;

* Light fixtures in hallway storing freezers;

* Floors in hallway storing freezers;

* Fan and lights above steam table in North unit;

* Juice machine;

* Radio, timer and phone; and

* Industrial mixer.

b. The following areas were in need of repair:

* Large open area in wall in hallway where freezers where stored;

* Reach in refrigerator in south unit not holding correct temperature for cold food storage;

* Caulking behind ware washing area with black mold like substance;

* Walls in dry storage with peeling/chipped paint and damage from canned goods; and

* Racks in reach in coolers with rust.

c. Dishwashing racks observed stored on the floor.

d. Refrigerator in south unit found at 50 degrees Fahrenheit. Milk products, yogurts and other protein rich items stored for service to residents. Milk was temped and was at 47.5 degrees F higher than the required 41 degrees for safe food storage. Facility did not have a process for monitoring temperatures of unit fridges to ensure kept at appropriate temperature levels for safe food storage.  

e. Entire box of red potatoes found in dry storage wilting and growing roots with fuzzy white substance. Staff 2 acknowledged those items were bad and should have been thrown away.

f. Ready shakes were found stored in multiple reach in fridges without dates to indicate when to use them by.

g. Reach in refrigerator on South unit observed without a thermometer to indicate what temperature food was stored at. A carton of eggs was observed stored in there with a use by date of 12/21/23.

At approximately 1:15 pm, the surveyor reviewed above areas with Staff 2 (Kitchen Manager) and Staff 1 (Administrator in training), who acknowledged the identified areas.

1. The actions that will be taken to correct the rule violation include:

a) Inservice with kitchen staff will be completed regarding proper cleaning protocol and what needs to be included in the cleaning routines.  Daily inspection and cleaning of the kitchenette has been assigned to kitchen staff to ensure food spills, splatters, loose food and trash debris, dirt dust or other matter is removed promptly.  Weekly Audit will be completed by the Director of Dietary or designee to ensure compliance. Results of audits will be reviewed in monthly QA meeting.

b) Inserviceswith kitchen staff will be completed regarding proper cleaning protocol and what needs to be included in the cleaning routines.  Weekly a deep clean of the kitchenette will be completed to ensuring any crumbs or matter missed during daily cleaning is capture on or underneath refrigerators, under cabinets, in drawers, on walls, trash collection areas and floors.  Deep cleaning will include cleaning the inside of the refrigerator. A Bi-weekly audit will be completed by the Director of Dietary or designee to ensure compliance. Results of audits will be reviewed in monthly QA meeting.

c) In service will be completed regarding the requirement of Daily cleaning of the handles of the reach in coolers and freezers in the main kitchen area will be cleaned by kitchen staff.  Weekly audit will be completed by the Director of Dietary or designee to ensure compliance.  

d) A monthly facility maintenance task will be added to inspect and cleaned light fixtures in the hallway where the freezers are located to ensure no debris is present in fixture and they are cleaned as needed. A monthly audit will be completed by the Administrator or designee to ensure compliance.

e) A cleaning task has been added to ensure that weekly the floors in the hallway where freezers are located will be cleaned by kitchen staff.  A weekly audit will be completed by the Administrator or designee to ensure.

f) Cleaning task has been added to the maintenance teams schedules to ensure that the fan and lights above the steam table are cleaned weekly to ensure removal of any dust or debris.  A weekly audit will be completed by the Director of Dietary or Designee. Results of audits will be reviewed in monthly QA meeting.

g) Inservice with kitchen staff will be completed regarding proper cleaning protocol and what needs to be included in the cleaning routines for all components of the Juice machine. Cleaning will be completed daily of the juice machine and a weekly deep clean and sanitation of equipment to include tear down of the machine and components has been implemented.  A weekly audit will be completed by the Director of Dietary or designee. Results of audits will be reviewed in monthly QA meeting.

h) The radio, timer and phone have all been removed from the kitchen area to eliminate any potential risk of contamination.  A monthly audit will be completed by the Director of Dietary to ensure compliance and that items do not come back into the environment.

i) Inservice with kitchen staff will be completed regarding proper cleaning protocol and what needs to be included in the cleaning routine for all components of the industrial mixer.  Cleaning will be completed daily of the industrial mixer and a weekly deep clean and sanitation of equipment to include tear down of the machine and components has been implemented.  A weekly audit will be completed by the Director of Dietary or designee. Results of audits will be reviewed in monthly QA meeting.

2. The action that will be taken to correct the violation include:

a) The large opening in the wall in the hallway where the freezer is will be repaired as well as a protective plate that is cleanable will be added to prevent future hole from occurring from the door handle hitting the wall when being opened.  The maintenance team has been assigned the repair task. Monthly inspection from the facilities team will occur to ensure any damage is repaired promptly.

b) Maintenance staff have completed the repair of removing caulking behind the washing area, it has been replaced with a cleanable waterproof stripping that locks out moisture and can be cleaned daily. Monthly inspection from facilities team will occur to ensure any no failure in the stripping is occurring.

c) Maintenance staff will complete repairs to wall in dry storage where paint is chipping and peeling and will place wall protection up that is cleanable to prevent future damage of the wall from canned good storage.  A monthly inspection by the facilities team will occur to ensure any damage is discovered and repaired promptly.

d) Inservice with kitchen staff will be completed regarding proper storage of dishwashing racks. A specialized rack to store the dish racks has been purchased and is now available for storage of dish racks. Daily audits will be completed by the Director of Dietary or designee.

e) Inservice with direct care staff and kitchen staff will be completed regarding proper temperature settings for refrigerated items ensuring temperature does not exceed 41 degrees in the kitchenettes.  A weekly audit will occur to check temperatures in the refrigerators to unsure temperatures are maintained to proper levels by the Director of Dietary or designee. Results of audits will be reviewed in monthly QA meeting.

f) Inservice with kitchen staff will be completed to ensure they understand the requirement to remove items that are expired or have spoiled from dry storage.  A weekly audit will be completed by the Director of Dietary or designee to ensure staff are following protocols to remove expired or spoiled items from dry storage. Results of audits will be reviewed in monthly QA meeting.

g) Thermometers have been added to all reach in refrigerators giving a visual indicator on what temperature food is being stored at to ensure it is not exceeding 41 degrees.  A log has been placed on each refrigerator for kitchen staff to check and document temperatures twice daily and dietary director is auditing daily. Weekly audits of refrigerator inventory will be completed to ensure that any items with expiration dates are removed.  Weekly audits will occur by the Director of Dietary or designee to ensure compliance. Results of audits will be reviewed in monthly QA meeting.

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 C 240.

See above plan to reach compliance.