The findings of the kitchen inspection, conducted 12/05/23, 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 revisit to the kitchen inspection survey of 12/05/23, conducted 02/23/24, 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 12/05/23, conducted 04/29/24, 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 ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
Observations of the facility main kitchen, food storage areas, food preparation, food service, and the Residential Care kitchenette area on 12/05/23 noted a buildup of splatters, spills, drips, and debris on:
- Interior of reach in refrigerators and freezers;
- Exterior and interior of ice machine;
- Stand mixer;
- Walls in food preparation areas;
- Interior of the Residential Care microwave;
- Can opener casing and blade;
- Exterior, sides, beneath, and behind the gas range and oven;
- Open shelving - surfaces, legs, and underneath; and
- Equipment throughout kitchen.
* There were undated and unlabeled foods in refrigerators.
* Raw eggs were stored on the top shelf above produce.
* Packaged foods were not dated when opened.
* Scoops were left in bulk bins of foods.
* Dented cans were noted in the upstairs dry storage area.
* The ice machine had a leak creating a puddle on the floor.
* There was not a small diameter probe thermometer to measure thin foods.
* Sanitizer buckets were observed with insufficient water to submerge towels.
* Staff were unaware of how to use sanitizer strips for the low temp dish sanitizer and the sanitizer buckets.
* Staff preparing food did not have hair restrained.
* Dish racks were stored directly on the floor.
* Staff washing dishes did not remove gloves and wash hands between rinsing and loading dirty dishes and putting away clean dishes.
* Caregiving staff, who assisted residents with incontinent care, did not use aprons while serving food.
* Staff were observed to not wash hands upon entry to the kitchen.
* Garbage cans did not have lids to use when not in use.
* The back door to the kitchen was left open allowing for the entry of pests.
Staff 1 (Executive Director) and the surveyor toured the kitchens on 12/05/23. Staff 1 acknowledged the food storage issues and the kitchens needed cleaning.
Dietary aide will clean; interior of reach in refrigerators and freezers, exterior and interior of ice machine, stand mixer, walls in food preparation areas, interior of the residential care microwave, can opener casing and blade, exterior, sides, beneath, and behind, the gase range and oven, open shelving- surfaces, legs and underneath, and equipment through the kitchen, if splatters, spills, drips and debri are found. If no spillage or debri is found dietary aide will still document that the area was monitored. Signed documentation on a log will be used to ensure duties are completed. Diatery Manager/ED will monitor logs weekly to ensure duties are being done correctly.
Food will be labeled and dated when opened and placed in the refrigerator. Dietary staff will be educated by an inservice training. Dietary Manager/ED will monitor labeling weekly for task completion.
Raw eggs have been moved to the bottom shelf of the refrigerator. Dietary taff will be educated on placing eggs on the bottom shelf when putting away deliveries by an inservice training.
Packaged foods will be labeled and dated when opened. Dietary staff will be educated by an inservice training. Dietary manager/ED will monitor labeling weekly for task completion.
Scoops have been removed in bulk bins of food. Staff will be educated by an inservice training. Dietary manager/ED will monitor labeling weekly for task completion.
Dented Cans have been removed and placed in a designated area. Dietary staff will monitor weekly for dented cans at deliveries and move them into designated area. Dietary staff will be educated on procedure by inservice training. Dietary Manager/ED will monitor weekly that cans have been removed.
Ice machine leak has been fixed with no observation of further leakage. Dietary Manager/ED will monitor monthly for proper function of the ice machine and sign off on the documention log binder.
Community has purchased and received a small diameter probe thermometer to measure thin foods. Dietary staff will be educated on where to locate the small diameter probe thermometer by inservice training. Dietary manager/ED will monitor weekly to ensure thermometer is in working condition.
Sanitization buckets have sufficient water to submerge towels. Dietary staff will be educated on how much water to place into the sanitization buckets by an inservice training. Dietary Manager/ED will monitor task compentency monthly and document in log binder.
Dietary staff will be educated on how to use sanitizer strips for the low temp dish sanitizer and the sanitizer buckets. Education will be in the form of inservice training.
Dietary staff have been privided Hair nets and hats to restrain hair. Dietary manager/ED will monitor and document in log book weekly for proper uniform
Dish racks will be placed in designated shelf near dish shelf. Dietary staff will be educated on the proper placement of the dish racks by an inservice training. Dietary Manager/ED will monitor weekly and document completion of task in log book.
Staff will be educated when washing dishes that they will remove gloves and wash hads between rinsing and loading dirty dishes and putting away clean dishes by inservice training. Dietary Manager/ED will monitor weekly and document completion of task in log book.
Health Services and Dietary staff will be be educated on wearing aprons when staff are handeling food after providing incontinence care by inservice training. Dietary Manager, ED and RCC will monitor Weekley for compliance and document in log book.
All staff will be educated to wash hands when entering a food preperation area by inservice training. ED/Dietary Manager/RCC will monitor weekly and document in log book of proper completion of task.
Garbage cans have proper lids to use when not in use. Dietary Manager will monitor proper and functional garbage lids weekly and document in log.
Magnetic screen door will arrive and be installed in Kitchen to prevent entry of pests when kitchen door to the outside is open 12/22/2023. Dietary Manager will monito the condition of the magnetic screen door Monthly and documnt in log book.
Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:
The facility's main kitchen in the MCC, the "Warming Kitchen" in the RCF, and the refrigerator in the MCC dining room were observed on 02/23/24.
a. Observation of the facility's reach-in refrigerators revealed the following foods were not dated, and/or labeled appropriately:
* Meat and bean mixture;
* Individual fruit servings;
* Marshmallow and fruit desserts;
* Sandwiches;
* Coffee cake slices;
* Desserts with whipped topping; and
* Individual cups of unidentified food items.
b. The garbage can near the prep area in the facility's main kitchen remained uncovered when not in use and did not have a lid.
c. The back door to the kitchen was left ajar allowing for the entry of pests. The facility had installed a magnetic screen door; however, it did not extend the length of the doorframe and was not closed.
d. Staff were unaware of how to test and which sanitizing testing strips to use for the solution in the sanitizing buckets.
e. Staff washing dishes were observed to not wash hands between rinsing dirty dishes and shelving clean dishes.
f. A moldy cantaloupe was observed in storage, and an open container of a cream based dressing was observed unrefrigerated in the dry storage area.
The kitchens were toured with Staff 4 (Dietary Manager) on 02/23/24. Photographs and a discussion of the findings occurred with Staff 1 (ED) and Staff 4 on 02/23/24 at 11:39 am. They acknowledged the findings.
Plan of correction for Stephanie Gardens annual kitchen inspection
1.Concerning foods not labeled and dated appropriately-
Plan in place and policy moving forward is as follows
a.All snacks scheduled to go out at 10 am, 3pm, and 7 pm, Noc shift are to be labeled and dated by dietary aide preparing them. The Snacks are to be rotated and used following the FIFO method and tossed after 3 days. Floor aides were instructed to date and label any items placed in warming kitchen refrigerator. The CDM/CFPP will do audits daily for 30 days, Weekly Audits going forward, administrator will do audits weekly, and the corporate director of dining services will do audits monthly to ensure policy is followed. CDM/CFPP has added this to weekly audit and logged in QA binder. Start Date 3/5/24
b.The unlabeled snacks that surveyor took picture of were from the previous day and were thrown out and new snacks made by CDM/ CFPP, dietary aides showed correct procedure for making snacks moving forward. Floor aides were instructed to date and label any items placed in warming kitchen refrigerator.
The correction for the system was demonstrated in a mandatory kitchen meeting held 3/5/24 by both CDM/CFPP and Corporate Director of Dining Services. The new system was in place 3/5/24.
2. Concerns with garbage can near prep area
Plan in place and policy moving forward is as follows
a.Stephanie Gardens purchased three Rubbermaid "hands free" garbage cans that were delivered 3/11/24. These have attached lids that open and close with a footstep on method. The CDM/CFPP will monitor weekly checks on garbage cans to ensure they are working to ensure 24/7 closed lids unless the footstep action is in play.
2.Concerns with door ajar-
Plan in place and policy moving forward is as follows
a.The hanging screen has been added 3/5/24 to create a top-to floor screen with magnets to close the screen from top to bottom. The Staff will not prop door open without ensuring screen is properly closed.
b.The correction for the system was demonstrated in a mandatory kitchen meeting held 3/5/24 by both CDM/CFPP, Maintenace Director and Corporate Director of Maintenance and Corporate Director of Dining Services. The new system was in place 3/5/24.
Plan of correction for D- F
D- The correct use of sanitizing strips- The correction for the system was demonstrated in a mandatory kitchen meeting held 3/5/24 by both CDM/CFPP and Corporate Director of Dining Services. The new system was in place 3/5/24. CDM/CFPP called Chemical company to set up a quarterly training going forward to ensure the sanitizer and strips are correctly used for testing. CDM/CFPP has added this to weekly audit and logged in QA binder. Start date 3/5/24.
E- Staff not washing hands between rinsing dirty dishes and shelving clean dishes-
The correction for the system was demonstrated in a mandatory kitchen meeting held 3/5/24 by both CDM/CFPP, Maintenace Director and Corporate Director of Maintenance and Corporate Director of Dining Services. Where CDM/CFPP demonstrated the correct way to handwash between clean/ dirty dishes. The new system was in place 3/5/24.
The CDM/CFPP will do audits daily for 30 days, Weekly Audits going forward, administrator will do audits weekly, and the corporate director of dining services will do audits monthly to ensure policy is followed. CDM/CFPP has added this to weekly audit and logged in QA binder. Start Date 3/5/24
F- Moldy Cantaloupe - All "room temperature" produce will be placed in proper bins and dated upon receiving. All food shall be kept in a "temperature controlled" area and monitored daily by cook that is on, the CDM/CFPP will audit as follows.
The CDM/CFPP will do audits daily for 30 days, Weekly Audits going forward, administrator will do audits weekly, and the corporate director of dining services will do audits monthly to ensure policy is followed. CDM/CFPP has added this to weekly audit and logged in QA binder. Start Date 3/5/24
There are no detail notes for this visit.
Based on observation, interview, and record review, 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 C 240.
There are no detail notes for this visit.
Based on observation, interview, and record review, 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.
Dietary aide will clean; interior of reach in refrigerators and freezers, exterior and interior of ice machine, stand mixer, walls in food preparation areas, interior of the residential care microwave, can opener casing and blade, exterior, sides, beneath, and behind, the gase range and oven, open shelving- surfaces, legs and underneath, and equipment through the kitchen, if splatters, spills, drips and debri are found. If no spillage or debri is found dietary aide will still document that the area was monitored. Signed documentation on a log will be used to ensure duties are completed. Diatery Manager/ED will monitor logs weekly to ensure duties are being done correctly.
Food will be labeled and dated when opened and placed in the refrigerator. Dietary staff will be educated by an inservice training. Dietary Manager/ED will monitor labeling weekly for task completion.
Raw eggs have been moved to the bottom shelf of the refrigerator. Dietary taff will be educated on placing eggs on the bottom shelf when putting away deliveries by an inservice training.
Packaged foods will be labeled and dated when opened. Dietary staff will be educated by an inservice training. Dietary manager/ED will monitor labeling weekly for task completion.
Scoops have been removed in bulk bins of food. Staff will be educated by an inservice training. Dietary manager/ED will monitor labeling weekly for task completion.
Dented Cans have been removed and placed in a designated area. Dietary staff will monitor weekly for dented cans at deliveries and move them into designated area. Dietary staff will be educated on procedure by inservice training. Dietary Manager/ED will monitor weekly that cans have been removed.
Ice machine leak has been fixed with no observation of further leakage. Dietary Manager/ED will monitor monthly for proper function of the ice machine and sign off on the documention log binder.
Community has purchased and received a small diameter probe thermometer to measure thin foods. Dietary staff will be educated on where to locate the small diameter probe thermometer by inservice training. Dietary manager/ED will monitor weekly to ensure thermometer is in working condition.
Sanitization buckets have sufficient water to submerge towels. Dietary staff will be educated on how much water to place into the sanitization buckets by an inservice training. Dietary Manager/ED will monitor task compentency monthly and document in log binder.
Dietary staff will be educated on how to use sanitizer strips for the low temp dish sanitizer and the sanitizer buckets. Education will be in the form of inservice training.
Dietary staff have been privided Hair nets and hats to restrain hair. Dietary manager/ED will monitor and document in log book weekly for proper uniform
Dish racks will be placed in designated shelf near dish shelf. Dietary staff will be educated on the proper placement of the dish racks by an inservice training. Dietary Manager/ED will monitor weekly and document completion of task in log book.
Staff will be educated when washing dishes that they will remove gloves and wash hads between rinsing and loading dirty dishes and putting away clean dishes by inservice training. Dietary Manager/ED will monitor weekly and document completion of task in log book.
Health Services and Dietary staff will be be educated on wearing aprons when staff are handeling food after providing incontinence care by inservice training. Dietary Manager, ED and RCC will monitor Weekley for compliance and document in log book.
All staff will be educated to wash hands when entering a food preperation area by inservice training. ED/Dietary Manager/RCC will monitor weekly and document in log book of proper completion of task.
Garbage cans have proper lids to use when not in use. Dietary Manager will monitor proper and functional garbage lids weekly and document in log.
Magnetic screen door will arrive and be installed in Kitchen to prevent entry of pests when kitchen door to the outside is open 12/22/2023. Dietary Manager will monito the condition of the magnetic screen door Monthly and documnt in log book.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 240.
There are no detail notes for this visit.