The findings of the kitchen inspection, conducted 10/02/23, 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 10/02/23, conducted 12/06/23, 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 second revisit to the kitchen inspection of 10/02/23, conducted 01/24/24, 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 proper food preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The facility kitchen was toured on 10/02/23, observations of the five facility kitchens, including food storage areas, food preparation, food service, and interviews with staff were conducted during the annual kitchen inspection.

a. Emerald House, the main kitchen, was toured at 10:05 am and identified the following:

* The exit door to the outside was fully opened, without a screen and allowed for the entry of pests;

* Multiple trash cans lacked covers;

* Air conditioning unit mounted above the ware washing area had brown splatters and debris buildup;

* Ice machine interior lid and air vents had a buildup of debris;

* The dry food storage area had less than a week supply of dry goods;

* Interviews with multiple staff identified on multiple days throughout the week the kitchen doesn't have the ingredients to prepare and serve what was on the menu;

* Interviews with staff also identified that there had been times that the kitchen didn't provide a written menu for residents;

* Interior shelf walls of the steam table and prep table had a large area of brown matter;

* Bottom shelf of the stainless-steel table to the right of the grill was covered in black matter and had a five gallon bucket of used food grease that had not been discarded;

* Buildup of food debris and grease behind and underneath the stovetop, oven and grill;

* Food splatter and debris buildup on the conveyor toaster and microwave;

* Drawer underneath the toaster and drink counter had dirty serving utensils and debris that had fallen into the drawer;

* Disposable food containers stored on the prep counter contained food splatter on them;

* Drains beneath bakery table and underneath the sink next to bakery table had a buildup of food waste;

* The walk-in freezer had food and debris on the floor;

* The exhaust fan cage blowing into the walk-in refrigerator had dust and debris;

* The walk-in refrigerator had multiple leftover food items that were beyond the discard date and continued to be stored on the refrigerator shelves;

* Ready to eat meat products were improperly stored and shelved with produce and on the upper shelves;

* Meat was wrapped in clear wrap or covered with parchment paper without a label or date;

* Under counter reach-in Continental refrigerator had multiple food items that were uncovered, unlabeled and not dated;

* Staff lacked knowledge of how to use sanitation test strips;

* Staff lacked good infection control related to use of aprons, hair restraints and hand hygiene between dirty and clean tasks;

* Multiple staff interviewed lacked knowledge of signs and symptoms of foodborne illness, transmission and prevention of foodborne illnesses including cross contamination and safe food handling processes;

* Staff failed to take food temperatures for all food prior to transporting the food to the warmer for hot holding; and

* Staff failed to ensure serving carts were clean and disinfected prior to placing plates and glasses for meal service to the dining room.

b. Crown House kitchenette was toured at 12:05 pm and identified the following:

* Splatters, spills, debris, drips were noted on the inside and outside of the microwave and toaster;

* Staff were not using sanitation test strips for the stationary rack dishwasher;

* The upright refrigerator was missing the temperature gauge; and

* All staff failed to have verification of a valid Oregon Food Handler card.

c. Barlow House kitchenette was toured at approximately 12:26 pm and identified the following:

* Splatters, spills, debris, drips were noted on the inside and outside of the microwave and toaster;

* The drain and surrounding floor under the single compartment sink had black/brown matter;

* Drain underneath the two-compartment sink had a buildup of debris;

* Floors throughout the kitchen was visibly soiled with dirt buildup, grass clippings, leaves and food debris; and

* The backsplash by the two-compartment sink was pulling away from the wall.

* Shelving used to store clean dishes had chipped laminate and was an unclean surface; and

* Gouges on cupboard doors rendering the surface uncleanable.

d. Diamond House kitchenette was toured at 12:37 pm and identified the following:

* Splatters, spills, debris noted on the toaster, interior /exterior of the microwave and drain under the three compartment sink;

* Multiple ceiling vents had buildup dust and debris;

* Multiple leftover food items were not dated or labeled in the upright refrigerator;

* Staff lacked knowledge and proper use of the three-compartment sink for sanitation of dishes;

* There was inoperable stainless-steel reach in refrigerator left discarded in the back of the kitchen; and

* All staff failed to have verification of a valid Oregon Food Handler card.

e. Astor House kitchenette was toured at approximately 12:56 pm and the following was identified:

* The upright refrigerator was missing the temperature gauge;

* There was a two-inch hole in the floor near the center island prep table;

* There was no soap dispenser for hand hygiene;

* There were no sanitation test strips for the stationary rack dishwasher; and

* There were splatters and food debris on the interior and exterior of the microwave and toaster.

The above findings were discussed with Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 10/02/23 at 1:10 pm. They acknowledged the findings.  

1. Each kitchen will receive a deep clean. The sink, shelving, and cabinets in Barlow will be repaired. An audit will be completed to ensure all applicible employees have a Food Handlers Card on file.

2. The Dining Services Director will receive additional training on Menu creation using the contracted platform and developing the shopping list from the menu. The Dining Services Director, Cooks, and Dining Services Aides will receive additional trainng on infection control, handwahing, signs and symptoms of foodborne illness, food temperatures, and use of test strips for kitchen equipment.

3. The Dining Services Director will review all areas weekly per the Dining Services - Quality Assurance Review Schedule.

4. The Executive Director will be responsible for ensuring compliance.

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:

Observations of the five facility kitchens, including food storage areas and food preparation on 12/06/23 revealed:

1. Emerald House, the facility's main kitchen, was toured at 1:37 pm.

a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust and garbage was observed on, in or underneath the following:

* Heated serving carts;

* Ice machine vents;

* Interior ice machine mechanism had black matter;

* Shelving below the steam table and the prep table;

* Stove;

* Grill;

* Oven;

* Microwave;

* Drawer underneath the toaster;

* Exhaust fan cage in the walk-in refrigerator; and

* Drains throughout the kitchen.

b. Observations of the walk-in refrigerator, reach-in refrigerator and dry pantry revealed the following foods were not covered, dated, and/or labeled appropriately:

* Rice;

* Gelatin dessert;

* Liquid egg;

* Low fat cottage cheese;

* Unidentified sauces;

* Salsa; and

* Creamy dressing.

c. Staff were observed not testing newly mixed sanitation solution prior to use.

d. Staff lacked good infection control related to the use of beard restraints, hand hygiene between dirty and clean tasks, and glove use.

2. Diamond House kitchenette was toured at 2:57 pm. The following was revealed:

* The microwave had food splatter. The interior surfaces of the microwave were peeling which resulted in an uncleanable surface;

* An open gallon of milk was not dated; and

* A frayed rag was in the freezer.

3. Astor House kitchenette was toured at 3:03 pm. The following was revealed:

* The microwave had food splatter. The interior surfaces of the microwave were peeling which resulted in an uncleanable surface; and

* An open container of half and half was beyond the discard date.

4. Barlow House kitchenette was toured at 3:10 pm. The following was revealed:

Splatters, spills, debris and drips were noted on the inside and outside of the microwave and toaster.

5. Crown House kitchenette was toured at 3:22 pm. The following was revealed:

Splatters, spills, debris and drips were noted on the inside and outside of the microwave and toaster.

The primary kitchen and kitchenettes were toured with Staff 4 (Dining Services Director) on 12/06/23, he acknowledged the findings. Photographs and a discussion of findings occurred with Staff 1 (ED) on 12/06/23 at 3:53 pm and was finalized at 4:24 pm. She acknowledged the findings.

1. The identified areas will receive a deep cleaning, the cleaning schedule will be updated and customized per individual cottage kitchen,the microwave in Astor and Diamond will be replaced.

2. Dining Services staff will receive additional training on the Cleaning Schedule, Dating and Labeling Food, Hand Hygiene, Glove use, Proper use of Beard Restraints, and Proper use of Sanitization Solution including testing prior to use.

3. Review will be completed weekly per the QA - Dining Services Review Schedule.

4. The Executive Director will be responsible to ensure compliance

Based on observation and interview, 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

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.

Refer to C240

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.

Refer to C240