The findings of the kitchen inspection, conducted 01/04/23, 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 of 1/4/23, conducted 4/11/23, 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 01/04/23, conducted 06/02/23, 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 revisit to the kitchen inspection of 1/4/23, conducted 8/9/23, 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, interview and record review it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-0000.  Findings include, but are not limited to:

On 01/04/23 at 10:35 am, the facility kitchen was observed to need cleaning in the following areas:

* Bottom shelf, fans and outside of doors of the reach in refrigerator;  

* Floors in the walk in refrigerator and freezer;

* Blue container lids in the dry storage area;

* Food bins containing oatmeal, flour and panko crumbs;

* Shelves below coffee/juice counter;

* Lower shelf containing cutting boards;

* Surfaces (sides/front/doors) and wall behind steamer, deep fat fryer, stove and grill;

* Vents within the hood above the stove/grill/fryer;

* Sliding clear doors under steam table storing dishes;

* Top of pole holding whisks next to the steam table;

* Sandwich refrigerator between the cutting board and door closure area;

* Fans operating above handwashing sink and prep area;

* Wall and ceiling surrounding the fan and sprinkler head in prep area;

* Ceiling vents in prep area and beverage counter;

* Dishwashing area: wall above and below the spray sink; drain and floor under the dishwasher; and

*Floors throughout the kitchen: underneath counters, deep fat fryer, stove/grill, dry storage, prep area, three compartment sink, ice machine and beverage area.

The following food items were improperly stored:

* Individual servings of ice cream were uncovered in the walk-in freezer and  a sheet pan of cake/brownies on a rolling cart in walk in refrigerator were uncovered.

The facility failed to ensure the dishmachine was operating according to the data plate rinse temperature of 180 degrees F:

* Several observations on 01/04/23 at 10:45 am of the rinse temperature gauge on top of the dishmachine showed the temperature registered between 140 and 150 degrees F.

* Interview with Staff 5 (dishwasher) indicated the gauge did not work and stated the temperature was not monitored.

* Staff 1 (Executive Director) was informed and they contacted Staff 3 (Kitchen Manager) and learned temperatures were taken and recorded manually with a thermometer placed in the dishmachine water after the rinse cycle ran.

* No rinse temperatures were recorded on the temperature logs.

* Staff 4 (Cook) took a temperature of the water at 11:10 am which read 156 degrees F.

* Maintenance director was immediately notified and service vendor was contacted for immediate repairs.  

The above areas were discussed with Staff 1 (Executive Director) and Staff 2 (Cook) on 01/04/23. The findings were acknowledged.

Dining Services Director (DSD) will ensure items requiring cleaning are on the daily and weekly cleaning checklists for dining staff.

Deep cleaning will be completed to address all items listed in citation.

DSD will review cleaning checklists and inspect daily on working days.

Executive Director (ED) will conduct weekly audits to ensure cleaning checklists are completed in their entirety as well as visual inspection of kitchen.

Dishwasher has been inspected and repair parts ordered. Repair will be completed once parts are received.

DSD will review wash and rinse temperatures daily on working days and will notify ED if out of required parameters.

ED will review dishwasher temperatures weekly with DSD.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-0000.  This is a repeat citation. Findings include, but are not limited to:

On 4/11/23 at 11:30 am, the facility kitchen was observed to need cleaning in the following areas:

* Fan blades and cages;  

* Bulk food bin lids;

* Surfaces (sides/front/doors) and wall behind steamer, deep fat fryer, stove and grill;

* Bottom of pole holding whisks next to the steam table;

* Sandwich refrigerator around edges and in-between divider areas;

* Wall and ceiling surrounding the fan and sprinkler head in prep area;

* Lower shelf where cutting boards were stored;

* Open shelving under steam table where serving pans were stored;

* Dishwashing area: wall above and below the spray sink; drain and floor under the dishwasher; and

* Floors throughout the kitchen: underneath counters, deep fat fryer, stove/grill, dry storage, prep area, three compartment sink, ice machine and beverage area.

* Floors underneath shelving in walk in cooler and freezer;

* Rolling baking rack stored in walk in cooler; and

* Walls behind equipment.

The facility failed to ensure the dish machine was operating according to the data plate rinse temperature of 180 degrees F.

* Several observations of the rinse temperature gauge on top of the dish machine showed the temperature of the rinse did not reach 180 degrees F. Records of dish wash temperatures reviewed from 04/01/23 through 04/11/23 documented a range of temperatures for morning, lunch and dinner of 156-176 degrees F, with no recorded temperature readings of 180 degrees F for the final sanitizing rinse.  Staff 1 (Executive Director) acknowledged the dishwasher had not been reaching 180 degrees but had thought it needed to be between 160 and 180 degrees F. S/he acknowledged the facility had been working with a vendor on multiple occasions to get the rinse cycle temperature higher. During this survey the highest the temperature would reach was 178 degrees F per the dial on the machine. The data plate on the dish machine did confirm that the minimum rise cycle temp should be 180 degrees F.

The above areas were discussed with Staff 1 (Executive Director) and Staff 2 (Kitchen Manager) on 4/11/23. The findings were acknowledged.

DSD will conduct deep cleaning party with dietary staff  where all equipment will be pulled and floors and walls deep cleaned.

Items listed are on weekly cleaning list. (fan blades, deli bar, whisk holder, etc) ED to create inspection checklist and conduct audits weekly after deep cleaning. If found unsatisfactory, ED will inspect daily on working days until completed.

Vendor will be contacted again to repair the dishwasher to obtain a minimum rinse temperature of 180 degrees.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-0000.  This is a repeat citation. Findings include, but are not limited to:

On 06/02/23 at 1:00 pm, the facility kitchen was observed to need cleaning and repair in the following areas:

* Surfaces (sides/front/doors) and wall behind steamer, deep fat fryer, stove and grill;

* Wall and ceiling in the prep area located in the back of the kitchen had built up dust debris;

* Wall above the spray sink in the dishwashing area had built up black matter;

* Floors underneath deep fat fryer, stove/grill, and walk in refrigerator and freezer had built up black matter;

* Sandwich refrigerator and reach in refrigerator had individual food items that were not properly stored, labeled and dated;

* The hand washing sink faucet handle was broken and wouldn't turn off; and

* The facility failed to ensure the dish machine was operating according to the data plate rinse temperature of 180 degrees F.

Several observations of the rinse temperature gauge on top of the dish machine showed the temperature of the rinse did not reach 180 degrees F. Staff 1 (Executive Director) acknowledged the facility had been working with a vendor on multiple occasions to get the rinse cycle temperature higher. During this survey, Staff 1 and the surveyor ran the dish machine nine consecutive times. The highest the temperature would reach was 176-178 degrees F per the dial on the machine. The data plate on the dish machine did confirm that the minimum rise cycle temp should be 180 degrees F.

Staff 1 and Staff 2 (Dietary Manager) stated they would call the vendor again for repair and directed kitchen staff to use the three compartment sink for sanitizing dishes and kitchen equipment.

The above areas were discussed with Staff 1 and Staff 2 on 06/02/23. The findings were acknowledged.

Staff will use 3 sink method until dishwasher is either repaired again or replaced. Dietary staff will continue to log daily temperatures once machine repaired/replaced. DSD will review daily on working days and report any temperatures out of parameters to ED.

Areas in which cleanliness was a concern have been addressed. Moving forward, ED will conduct bi-weekly audits of kitchen as well as ensuring all stored foods are covered, labeled, and dated.

Based on interview, observation and record review, it was determined the facility failed to ensure their re-licensure 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 and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C240.

Refer to C240

Based on observation 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.

Reference C240

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 C240.

Refer to C240

Based on observation and interview, 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 C240.

Refer to C240