The findings of the kitchen inspection, conducted 02/29/24, 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 re-visit to the kitchen inspection of 02/29/24, conducted 05/17/24, 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 revisit to the kitchen inspection of 02/29/24, conducted 07/22/24, 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 facility was found to be in substantial compliance.

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 main facility kitchen on 02/29/24 from 11:30 am thru 2:00 pm and 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:

* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath and on top of the dish machine;

* Kitchen drains;

* Ceiling vents and light fixtures;

* Walls throughout kitchen;

* Interior of microwave;

* Interior and exterior of toaster oven;

* Interior and exterior of ovens:

* Grill top and range top;

* Open shelving under steam table;

* Open shelving/table under steamer;

* Sides of industrial equipment (oven/range/grill);

* Industrial and counter top mixers;

* Base holding mixer and shelving/space bellow mixer;

* Large can opener and housing;

* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges;

* Metal rack shelving in walk in cooler;

* Walk in cooler floor;

* Metal rack shelving storing equipment and dishes;

* Utility racks;

* Legs and wheels of equipment, steam table, carts, shelving, prep spaces;

* Meal service delivery and utility carts;

* Juice machine;

* Coffee station and drawers/cabinets under in kitchen and in dining room;

* Interior of drawers storing cooking utensils and measuring cups;

* Go rack plastic cover;

* Light fixture above hand washing sink dirty and with bug accumulation;

* Window seal by clean dish storage;

* Dishwashing rack dolly;

* Interior and exterior of ice machine; and

* Freezer fan cage.

b. The following areas needed repair:

* Caulking in ware washing area with black matter debris buildup;

* Multiple utility carts with cracks/damage;

* Multiple light fixtures with cracks/damage;

* Light switch near ware washer with crack and missing piece from outlet;

* Temperature gauge of walk in cooler was not operational;

* Large accumulation of frost/ice build up in walk in freezer;

* Right oven not operational;

* Large strip of smooth protective covering removed/chipped away from shelving under steam table with exposed pressed wood;

* Multiple metal racks storing food items and clean dishes were noted to be rusty. Other racks had protective coating removed/worn yielding an non smooth surface for appropriate cleaning;

* Cracks/chips in tile entering kitchen with black matter/dust/dirt debris build up in cracks; and

* White cupboard area in kitchen with chipped paint exterior corners and interior shelving exposing porous wood surfaces.

c. Multiple food items/packages/containers found in cold food and dry food storage that were not covered or properly closed/sealed and exposed to potential contamination.

d. Dirty dishes were found stored on clean dish side of dish machine area, along with observed food debris. Piles of dishes were observed stacked up all along the dish washing area and overflowing into, on and around the 3-compartment sink area.

e. Multiple dry good food items were not dated when opened.

f. Multiple plastic spatulas were found in poor repair with chunks missing needing replaced. Cutting boards were noted to be heavily scored and/or stained and needing to be replaced.

g. Single service forks/spoons were stored food contact surface side up and not protected from potential contamination.

h. Hand washing sink did not have hot water consistently. Went from hot to warm to cold all within 30 seconds.

i. Temperature gauge to walk in was not operational. Kitchen staff had temporary thermometer located in the center of the walk-in cooler. Requirements are for temperature measuring device at the warmest part of the cooler to ensure all food is stored at 41 degrees or below.

j. Kitchen staff was observed to remove tomato from walk in cooler and slice for cheese burger without washing prior to slicing and serving.

k. Kitchen staff was observed prepare 2 hamburgers to order and serve to resident without checking temperature to ensure it reached the appropriate safe temperature prior to serving.

l. Multiple sanitation rags were observed lying about the kitchen prep areas and not in appropriate sanitizer buckets.

m. multiple kitchen staff did not have facial hair or hair restrained as required.

n. Dining area was observed to have preset silverware that was not protected from potential contamination as required.

Staff 2 (Dining Service Director) toured the kitchen with surveyor and acknowledged areas of concern. Surveyor and Staff 2 reviewed kitchen cleaning lists which had multiple missing items/signatures. Staff 2 acknowledged multiple cleaning items had not been done.

At 1:30 pm, surveyor reviewed identified issues with Staff 1 (Business Office Manager) and Staff 3 (Wellness Director), they acknowledged the areas of concern.

Maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules:

CLEANING/CLEANING TASK LISTS

?The Executive Director has scheduled a deep cleaning day on Wednesday 4/24/2024. This will consist of the new Dining Service Director, Executive Director, Plant Ops Director, Business Office Manager, Licensed Nurse, and RCC. My plan is that now with a new Dining Services Director, we will get the kitchen deep cleaned as a team and set the tone for the new DSD and current and new kitchen staff.

Completion Date: 4/24/2024.

?The Executive Director has also created a daily, weekly, bi-weekly, and monthly task lists for the kitchen to ensure we are following up on all tasks to maintain the kitchen in a sanitary clean position.

?The Plant Operations Director and Community Relations Director perform a weekly walk through of the community, I will provide them both with the detailed weekly, bi-weekly, and monthly task lists, and will highlight areas they will be paying close attention to. The Plant Operations Director has also already started the minor repairs needed in the kitchen, such as protective covering, light switch, and light fixtures.

?The Executive Director has provided our community Plant Operations Director with the list from the statement of deficiencies received during the State of Oregon's Feb 29, 2024, observation of the kitchen, and goal dates have been created. This consists of the details of ensuring the kitchen is in good proper working order and maintained to the expectations of the State.

Completion Date: Daily, Weekly, Bi-Weekly, Monthly

Kitchen carts, utensils, and other kitchen essential items.

?Executive Director and Dining Services Director will walk through the kitchen on Monday 4/22/2024, to perform an audit of the appliances, cooking utensils, spatulas, cutting boards, measuring cups, etc. to visually assess the condition of these items for signs of wear and tear, scratches, and corrosion. If needing to be replaced, we will make a list of the items to purchase. The plan is for all items needing replaced to be ordered/purchased on the same day of this audit.

Completion Date to place the orders for items needed, 4/22/2024.

Right Side of Oven not operational.

?We have had Central Mechanical out to repair this and were told there is a part needed that is hard to find. I will follow up on this asap, gather a couple bids from other companies if needed, and get this taken care of.

Completion Date to collect Bids and schedule repairs: Thursday 4/26/2024.

Metal Racks Rusted

?The Executive Director has found metal racks on Amazon and will have the Plant Operations Director measure all areas needing racks, so I can get these ordered. The plan is to have them ordered and on their way to the community by the end of week next week April 26, 2024.

Completion Date to place these orders: 4/26/2024.

KITCHEN FLOORS

?In the task lists I have created; we will be deep cleaning the kitchen floor. Once this is done, the Plant Ops Director, Dining Services Director and myself, will assess what a good plan is for getting the floor cracks and chips repaired.

Completion date to assess repairs and complete repairs: 5/31/2024, to fit into our monthly budget.

WHITE KITCHEN CUPBOARD

?This cupboard is used to store kitchen dishware. The plan is to have Plant Operations and Maintenance assistance assess the cupboard and let me know if it should be replaced or repaired and re-painted.

?Completion Date: 4/26/2024

FOOD OPEN DATES

?The Dining Services Director will perform an audit of ALL food in Dry Storage on Monday 4/22/2024, to ensure proper packaging, open dates, exp dates, etc.

?The Dining Services Director will perform an audit of ALL refrigerated food on Tuesday 4/23/2024.

?The Dining Services Director will perform an audit of ALL freezer items on 4/24/2024.

?The Dining Services Director will perform an audit of ALL spices etc that is not stored in the areas above.  

Completion Date for all of the above: 4/26/2024

DISHES

?We have a good system for cleaning and storing clean versus dirty dishes. I am surprised to hear that this was an issue during the survey of the kitchen, so will announce during the ALL staff meeting on April 25, 2024, that this was an issue on Feb 29th and discuss the reasons why we should never have clean dishes near dirty dishes due to contamination. The Executive Director will have a signed list of all employees that this has been reviewed with.

Completion Date: 4/25/2024

HAND WASHING SINK WATER TEMPERATURE

?The Executive Director has discussed the issue with the water temperature of the hand washing sink with the Plant Operations Director. My plan is to contact ARC plumbing to address this. We will have called and scheduled a day and time for ARC plumbing to come out, no later than Monday April 22, 2024.

Completion Date for scheduling the assessment and repair: 4/26/2024.

WALK IN COOLER

?The Executive Director discussed this with the Plant Operations Director and has been told that the thermometer that was placed in the middle of the walk-in cooler is not the thermometer used to ensure the temperature of the walk in is up to code. As of yesterday 4/18/2024, Plant Ops states he will ensure the thermometer in the walk-in fridge, and freezer are both in working condition and temping properly. This will be done during the scheduled day for deep cleaning on Weds 4/24/2024. If needed, new thermometers will be purchased along with the other supplies needed.

Completion Date: 4/24/2024

HAND WASHING

?The Executive Director has printed proper handwashing procedures for all Cascades of Stayton staff and will discuss/review this during the 4/25/2024 ALL staff meeting. Executive Director will also have a signed document showing the Inservice was performed and completed along with staff signatures.

?Compleion Date: 4/25/2024.

FOOD TEMPING

?On Feb 29th, 2024, it was observed by the state surveyor that our former Dining Services Director served a hamburger patty without temping the meat patty first.  In speaking with this former DSD, he stated he must have been nervous. I have discussed with the 2 cooks we currently have on staff that ALL food must be temped prior to serving and during serving out. They both have a good understanding of this.

Completion Date: 4/28/2024

SANITATION RAGS

?The Executive Director will ensure new DSD and ALL kitchen staff are reeducated on where to store clean and dirty wash rags. I will also reeducate ALL kitchen staff on the importance of using specific buckets when sanitizing, storing, and washing the sanitation rags during our monthly ALL staff meeting on 4/24/2024. The Executive Director along with the Dining Services Director will monitor this going forward.

Completion Date: 4/28/2024

FACIAL HAIR

?The Executive Director will discuss the standards for facial hair and having hair pulled back when in the kitchen at the 4/24/2024 ALL staff meeting.  

Completion date: 4/24/2024

SILVERWARE

?The Executive Director has discussed the need to ensure the silverware is protected from potential contamination, and staff are now folding the silverware into the napkin when setting the tables. The Dining Services Director, Resident Care Coordinator, Business Office Manager, and Community Relations Director walk the dining room prior to mealtimes to ensure the tables are set properly. I will be creating a schedule for all of our department heads designating days for each department head to assist with overseeing this.

Completion Date: 4/26/2024

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. This is a repeat citation. Findings include, but are not limited to:

Observation of the facility kitchen on 05/17/24 between 12:25 pm and 2:26 pm revealed the following:

a. There was an accumulation of food spills, splatters, loose food, dirt, dust, and/or black matter visible on the following:

* Interior of the toaster oven;

* Industrial and countertop mixers; and

* Trays on the shelving below the countertop mixer.

b. The following needed to be repaired or replaced:

* The walk-in freezer had a build-up of frost and ice; and

* The protective coating on multiple metal racks was wearing off in places, leaving an uncleanable surface.

c. Multiple food items/packages/containers found in the walk-in cooler and freezer and in the dry food storage were not labeled, dated, and/or properly closed or sealed and were exposed to potential contamination.

d. Multiple dry good food items were not dated when opened.

e. Multiple kitchen staff did not have facial hair or hair restrained as required.

The kitchen was toured and the above areas were reviewed and discussed with Staff 4 (Executive Director) on 05/17/24 at 2:20 pm. She acknowledged the findings.

C240 Tag ( a )

Deep cleaning of the kitchen will be completed by end of day Friday.

To maintain compliance, a more detailed task list has been created by Executive Director to include all kitchen staff as well as Executive Director, Plant Operations Director, Business Office Manager, Licensed nurse, etc.

A walkthrough of the kitchen will be performed weekly by the Executive Director or designee to ensure compliance and completion of these task lists. This includes the regular cleaning (inbetween meals) of the food splatters on the side of the stove/ovens, toaster oven, Countertop mixer, trays on the bottom of the shelves in kitchen, food carts, the sweeping and mopping of entire floor to include underneath shelves and counters.  

Please note: Since the last re-survey vist the industrial counter top mixer has been removed as we were not using it.

C240 Tag ( b )

The build up of ice in the walk in freezer, was taken care of by our former Dining Services Director one day after the last site visit. Since Executive Director and Plant Operations Director have put eyes on this area 1x weekly to enure it does not get to this state again.  

To maintain compliance, the task of placing eyes on this area during the weekly walkthrough has been added to the Dining Services Directors task list. At this time, Executive Director or designee will perform this walkthrough of the walk-in freezer once weekly to ensure there is no build up of ice or any other issue. Once a Dining Services Director is hired and trained, this task will then be given to the Dining Director to oversee.

In the event there is Ice build up, reporting staff will report to the Dining Services Director who will then report to the Executive Director, and Plant Operations Director.

To maintain compliance a detailed look on how to de-ice the are will be availble to the Dining Services Director, Plant Operations Director, and kitchen staff. This will be kept in a binder of task lists etc in the unlocked office shelf in the kitchen. The binder is labeled "Kitchen Compliance", and staff have .  

Metal racks: I (Executive Director), apologize as i thought the metal racks would need to be replaced by next years site visit, so I had only looked up bids and shared the information with our home office.

To ensure compliance, I will request that our community Plant Operations Director measure the racks again tomorrow 7/10/2024 and provide me with the measurements and quantity of racks needed to be in compliance. The racks will be ordered by Executive Director by end of day Wednesday 7/11/2024 and a receipt of purchase will be placed with this plan of correction for your review.

Items already ordered and replaced, 2 new food carts, new cooking utensils, and repairs noted during the initial Survey have all been completed.

C240 ( c and d )

An immediate walkthrough of the walk-in dry food storage, the walk-in fridge, walk-in freezer, and of the areas where spices are kept was performed after the last site visit and this has been included on the new detailed task list for cooks and dining aides. All staff are aware that if any package/container in the kitchen is opened, it is to be closed properly to avoid contamination, and it is to be dated and labeled. The stickers for this are kept above the area where the industrial mixer was kept and to maintaun compliance of this, the Dining Services Director or designee will include this in the weekly walk through to avoid open non-dated foods and to keep the wasted food to a minimum. This specific task has been added to the Dining Services Director's and Cook's task list to ensure they are checking off daily stating they have dated all opened packages for the day.

Walk throughs have also been performed every other day at this time by Executive Diretor or designee to ensure we are looking for opened packages, for dates, labels, and to ensure opened packages/containers in all walk-ins are closed properly to avoid contamination.

C240 ( e )

All staff, including cooks, dining aides, and support staff have been notified of the need to restrain hair and/or facial hair when working in the kitchen and dining room. I have created a sign of what is considered an effective hair restraint, which includes items such as hats, hair coverings, hair nets, and facial/beard restraints. I have also included rubber bands and clips that can also effectively restrain hair.

To maintain compliance, Executive Director or designee has ordered beard coverings and size 20inch hair nets to make keeping in compliance easier for the staff working in the kitchen.  

Tag C455

Unfortunately, we did not meet the expectations of the plan of correction created previosuly. The tasks added have made for a more detailed task list that includes Executive Director, Plant Operations Director, kitchen staff and designees.

Based on interview and observation, 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