The findings of the kitchen inspection, conducted 9/8/23, 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 re-visit to the kitchen re-licensure survey of 09/08/23, conducted on 11/08/23, 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 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 areas were reviewed on 9/8/23 from 10:45 am through 2:30 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:

* Fans blades and cages in cooler;

* Ceiling in walk in cooler;

* Ceiling vents and ceiling surrounding vents;

* Industrial mixer;

* Interior of unit microwaves;

* Unit reach in refrigerators/freezers;

* Half walls of unit dining areas;

* Cupboards where food stored in activity space;

* Oven in activity space;

* Areas around facets in all kitchenettes with mold like residue; and

* Carpet rug in one of kitchenettes was dirty.

b. The following areas were in need of repair:

* Walk in freezer door, ceiling and racks with ice build up;

* Unit kitchenettes and dining area walls with pealing/scratched/scuffed paint;

* Janitor closet in kitchen with pealing/missing paint, small hole in wall;

* Unit reach in refrigerators with damage to inside. One with door seal detached;

* Caulking around handwashing sink damaged/missing/in need replacement.

c. Multiple cutting boards, plastic storage containers with damage or heavy scoring and staining rendering items not to be smooth and cleanable as required. Oven mitts in kitchen found with rips and tears exposing cloth padding. Small fry pan damaged and in need of replacement.

d. Microwaves in kitchen and multiple kitchenettes with staining, rusting and protective coating pealing.

e. Ready To Eat (RTE) food items (Rice Krispy treat and cookie) found stored in unit drawer uncovered and exposed to potential contamination. Drawer with visible food debris.  

f. Multiple unit refrigerators without thermometers to monitor temperatures to ensure food items stored at 41 degrees F or less. Fridge in Daisy unit had a thermometer but when checked was at 48 degrees F. Milk stored in that refrigerator was checked and temperature was at 45 degrees F. Facility did not have a process for staff to monitor temperatures of unit refrigerators to ensure cold food items were stored at appropriate temperatures. Items in that refrigerator were discarded.  

Staff 2 (Dietary Manager) toured the kitchen areas with the surveyor and acknowledged the findings. At approximately 2:00 pm, the surveyor reviewed above areas with Staff 1 (Executive Director) who acknowledged the findings.

A. 1. A detailed cleaning checklist including the following areas will be created for the Dining Services team to complete: Fan blades and cages in cooler, ceiling vents and ceiling surrounding the vents, the industrial mixer, interiors of kitchen and unit microwaves, interiors of kitchen and unit refrigerators and freezers, half walls of unit dining areas, cupboards where food is stored in the activity space, the oven in the activity space, areas surrounding the faucets in the kitchen and units and the carpet rugs in the unit kitchenettes.

2. Training of current and new members of the Dining Services team will include a review of the cleaning checklists as a building procedure. Employees will be required to sign the cleaning checklist as an ackowledgement of the expectations.

3.The areas that have been listed that need correction will be evaluated on a weekly basis moving forward.

4. The Dietary Services Director and Maintenance Director will monitor the completion of the corrections listed.

B. 1. Repair of the following areas will be tasked to the Maintenance Director:

Walk-in freezer door, ceiling and racks ice build-up- call to manufacturer of walk-in freezer seeking local repair assistance. Thorough removal of existing ice build-up.

Unit kitchenettes and dining area walls that have pealing/scratches/scuffed paint- Fresh paint and kick-guard will be installed to prevent further damage.

Janitor closet in kitchen with pealing/missing paint, also with a small hole in the wall- All items will be removed from the closet for a fresh coat of paint and repair/patch for the hole. When items are put back in the closet they will be well-organized.

Unit reach-in refrigerators with damage- All unit refrigerators will be replaced.

Caulking around handwashing sink is damaged/missing- Kitchenette sinks will be deep cleaned and re-caulked.

2. The areas that were in violation will be added to TELS (tracking software for maintenance/upkeep of community) as a task/review for the Maintenance Director.

3. The TELS tasks will be scheduled monthly.

4. The Executive Director will review completion of the tasks with the Maintenance Director.

C. 1. Inventory of kitchen food preparation products will be completed and will note the specific items needing repair. Items that were listed included: cutting boards, plastic storage containers, oven mitts, small fry pans. Once items inventoried, replacements will be ordered.

2. Preparation product inventory will be implemented as a standard practice moving forward.

3. Product inventory will be evaluated monthly.

4. The Dining Services Director will review needs and order with Executive Director.

D. 1. Unit microwaves as well as microwave in the kitchen will be ordered and replaced.

2. Review/evaluation of the microwaves will be added to TELS for the Maintenance Director to complete.

3. The TELS task will be scheduled monthly.

4. The Executive Director will review completion of th etask with the Maintenance Director.

E. 1. Unit kitchenettes will receive a deep clean.

2. A review of where/how food items are to be stored will be completed at our next All-Staff Meeting, 10/19/2023. Our NOC team will be tasked with a Weekly Deep Clean checklist for the unit kitchenettes.

3. The Weekly Deep Clean checklist will be evaluated weekly as a TELS task.

4. The Maintenance Director will monitor the Weekly Deep Clean checklist in the TELS program.

F. 1. Unit refrigerators will have a thermometer installed to ensure food items are stored at 41 degrees F or less.

2. The Dining Services team will be responsible for taking/recording temperatures of the unit refrigerators daily.

3. Temperatures will be logged daily. The temperature logs will be reconciled on a monthly basis.

4. The Dining Services Director will present the temperature logs to the Executive Director for review.   

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 C 240.

Refer to C 240 POC