The findings of the kitchen inspection, conducted 01/30/24, 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 01/30/24, conducted 05/01/24, 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 second re-visit to the kitchen inspection of 01/30/24, conducted 06/28/24, 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:

Observations of the kitchen on 1/30/24 at 10:30 am through 2:00 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:

* Drain under/near dish machine;

* Dining room beverage area;

* Ceiling fire sprinklers;

* Floors throughout kitchen and dining room;

* Open shelving under the steam table;

* Interior and exterior of ovens;

* Open shelving next to stove;

* Baking rack;

* Door thresholds;

* Interior and exterior of deli refrigerator cart;

* Sink in beverage area; and

* Cabinet where trash can was stored in beverage area.

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

* Missing area of threshold floor cover with dirt and debris built up;

* Caulking around dish machine area with black substance buildup;

* Areas of cracked or missing tile flooring/cove base; and

* Gaps in ceiling tiles above stove/grill area.

c. Food items found in dry good storage, cooler and freezer were found not covered/sealed to prevent potential contamination.

d. Brown cutting board was observed heavily scored and needing replaced/resurfaced. Multiple water pitchers/carafes were found heavily scored and need of replacement. Multiple sauté pans were found with scrapes/scratches in non stick coating.

e. Two cans of food were observed sitting on the floor.

f. Green scratch pad for dish cleaning found heavily worn with pieces of pad pulling away from cleaning surfaces. Staff acknowledged cleaning items needed replaced.

g. Dish rack observed overloaded with items overlapping each other preventing all areas of dishes to be effectively sanitized.

h. Mops and brooms stored on the floor in janitor closet.

i. Sink between ware washing area and 3 compartment sink had hand washing directions posted however there was no soap or paper towels. The sink near the food line had no hand washing postings and all staff were observed to utilize that sink for hand washing. Facility must designate a sink for hand washing and not be used for any other task. Hand washing sink must have clearly visible postings dedicating it as the hand washing sink.

j. Kitchen staff member did not have facial hair restrained as required.

On 1/30/24, Staff 2 (Dietary Manager) toured the kitchen with the surveyor and acknowledged the above findings. At 1:30 pm, surveyor reviewed findings with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations). They acknowledged areas in need of correction.

1. All areas identified in subsections a-j that were found to be deficient are in process of being cleaned, repaired, replaced and policies are being implmented/updated where needed.

2. To ensure that this violation does not happen again, all areas identified in subsections a-j will be monitored via cleaning schedules and a kitchen sanitation inspection audit tool.

3. The areas indentified in subsections a-j will be monitored per the frequency identified on the cleaning schedules and the kitchen sanitation inspection audit tool. 4. The Dining Services Director will be responsible to see that the corrections are completed/monitored by reviewing the cleaning schedules and kitchen sanitation inspection audit tool on a weekly basis

Based on observation and interview, 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 kitchen on 05/01/24 at 1:45 pm through 2:45 pm revealed the following:

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 fire sprinklers;

* Floors throughout kitchen and dining room;

* Kitchen mats with food debris build up;

* Open shelving next to stove;

* Baking rack;

* Interior of deli refrigerator cart;

* Metal racks in walk in cooler; and

* Cooling fan cages and ceiling in walk in cooler.

b. Food items found in dry good storage, cooler and freezer that were not covered/sealed to prevent potential contamination. Container of macaroni salad was dated 03/25/24 well past 7 days. Manufactures use by date was illegible. Staff 1 (Dietary Manager) discarded the container.

c. Kitchen staff member did not have facial hair restrained as required.

d. Tableware for dinner meal was set at 1:45 pm. Staff 1 validated dinner meal was served at 4:30 pm. Staff 1 acknowledged utensils were not protected from potential contamination and was set greater than 30 minutes prior to meal.

On 05/01/24 at 1:45 pm, Staff 1 (Dietary Manager) toured the kitchen with the surveyor and acknowledged the above findings. There was no administrator or ED at time of survey to review findings.

C240A:

1. Deep clean of kitchen completed.

2. Cleaning checklist in place, in addition to staff training

3.  Weeky review of kitchen cleaning checklist and overall sanitation of the kitchen

4. DSM/ED

C240B:

1. Removal of all outdated/open-unlabeled foods from kitchen.

2. Staff Training regarding food storage and labeling of foods.

3.All foods will be monitorded daily for quality and freshness.

4. DSM/ED or other designee

C240C:

1. Hairnets in place

2. Staff training regarding hair/beard restraints.

3. To be reviewed daily

4.DSM/ED or other designee

C240D:

1. All tableware was removed, staff training took place to ensure tableware is not placed prior to meal service.

2. Tableware to be set as residents come in to sit in dining room.

3. Dining room will be monitored throughout the day to ensure tableware is not placed prior to residents being seated.

4. DSM/ED or other designee.  

Based on interview and observations, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C240.

Refer to C240