The findings of the kitchen inspection, conducted 12/22/23, 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 revisit to the kitchen inspection of 12/23/23, conducted 04/09/24, 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, 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:

Observation of the kitchen on 12/22/23 at 9:40 am through 1:30 pm revealed the following deficiencies:

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:

* Ceiling vents/smoke detector and sprinklers;

* Floors underneath shelving in dry storage;

* Fan cage, ceiling in reach in cooler;

* Interior of reach in fridge/cooler/freezers;

* Industrial can opener and housing;

* Exterior and interior of range/ovens;

* Interior of microwave;

* Shelving where dishes were stored/dried;

* Handheld knife sharpeners;

* Interior of drawers and;

* Area behind hand washing sink.

b. The following areas were found in need of repair:

* Cabinet under prep sink with visible water damage;

* Several cabinets/cupboards with damage to surfaces causing exposed porous wood;

* Hand held can opener blades were rusty;

* Industrial can opener blade with protective coating peeling or peeled off and in need of replacement;

* Older reach in cooler with areas of rust, damage and heavy build up of food debris. Temperature gauge on outside of fridge not accurate;

* Caulking in dishwashing area was found with black debris;

* Gap found between ceiling and piping in main kitchen yielding a hole where potential pests could gain entry to kitchen;

* Small refrigerator in dining area with heavy frost build up in freezer;

* Caulking behind sink in memory care kitchenette with debris build up/black substances; and

* Cabinets in memory care kitchenette with water damage and/or exposed porous wood.

c. Multiple cutting boards were found stained and/or heavily scored and in poor repair.

d. Dishwashing racks were stored on the floor. Facility staff were observed overloading rack for washing/sanitizing so that all parts of items to be washed/sanitized were not accessible yielding process ineffective.

e. Industrial dishwasher was not registering appropriate amount of chemical sanitizer after several attempts. Review of logs showed no data entries for seven days. Staff validated it was their process to check/validate appropriate concentration of sanitizing agent every day. Staff 2 acknowledged it had not been documented as done for past week. Facility unable to validate when machine had stopped effectively sanitizing dishes.  

f. Ready Care shakes were not dated when removed from frozen state to ensure consumed within 7-14 days. Staff were not able to verbalize when they were to be used by or how to validate they were acceptable to serve to residents.

g. Scoops were found stored in multiple bulk food item bins.

h. Dishes in memory care unit were put away/stored wet with evidence found of moisture in clean dishes and water damage on shelving.

i. Staff in memory care placed items in both sinks and were observed to wash hands in sink with dishes. No sink was dedicated for washing hands during meal service.

j. Memory care staff were observed serving food to residents without hair effectively restrained as required.

The surveyor reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas. At approximately 1:15 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Executive Director). S/he acknowledged the areas.  

1. All items that are in need of repair, cleaning or replaced have been adressed in kitchen and memory care kitchenette. Staff training has been done on health shake pulling and dating, hand washing sink and hair effectively restrained during  meal service.

2. Kitchen has a daily, weekly and monthly cleaning schedule for all kitchen staff. Kitchen manager will update and change cleaning items as needed for kitchen needs. Maintenance request/repairs are all logged into TEL's and monthly walk through of kitchen will be done. Training for care staff will be done upon hire and on going monthly audits and training in dining service.

3. Monthly walk throughs of the kitchen/kitchenettes and monthly dining/serving audits in each dining room.

4. Administrator, Dietary Manager, Maintenance director

Based on observation, record review 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.

Refer to C240