The findings of the kitchen inspection, conducted 10/10/23, 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 10/10/23, conducted 02/01/24, 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 10/10/23, conducted 04/04/24, 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 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:

Observations of the facility kitchen areas were reviewed on 10/10/23 from 10:45 am through 3:00 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:

* Drains throughout kitchen;

* Floors throughout the kitchen;

* Reach in coolers/freezers;

* Walk in freezer floor;

* Ceiling vents and tiles;

* Interior/exterior of microwave;

* Industrial can opener and housing;

* Industrial mixer and table;

* Stainless steel shelving throughout kitchen;

* Interior of drawers where cooking utensils stored;

* Waffle makers;

* Food delivery carts;

* Range top, ovens, grill top;

* Knobs, handles of appliances and equipment;

* Caulking around the perimeter of dish machine and hand washing sinks; and

* Reach in coolers with mold build up on door seals.

b. The following areas were in need of repair:

* Large opening in ceiling above a food prep area.

c. Industrial and tabletop mixers observed stored uncovered while not in use. Industrial slicer observed not covered when stored.  Multiple cooking pots, pans and bowls stored uncovered and open to potential contamination.  

d. Multiple kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required.

e. Multiple cutting boards were found heavily scored and stained.

f. Multiple food items found stored open to contamination in freezers, reach-in and walk-in coolers. Food items observed stored without labeling or dating as required. Items noted in refrigerator stored past 7 days.

g. Dry bulk food items were observed with scoops stored in the bins placing the food items at risk of contamination from the scoops.

h. Trash cans observed without lids. Staff 2 (Dining Services Director) confirmed trash cans did not have lids to cover them when not in use as required.

i. Multiple cans of food were found damaged/dented and stored in with ready to use stock.

The surveyor toured the kitchenettes in Aspen and Maple units and observed the following:

*Flooring was dirty and torn/peeling from seams and heavily scratched/scored in areas, not a smooth/cleanable surface.

* Reach in refrigerators and freezers with food debris, spills, drips.

* Reach in refrigerator in Maple without thermometer to ensure food items stored at appropriate temperatures.

* Multiple food items found in both units without use by dates or past their use by dates.

* Microwaves with dried food debris.

* Microwave in Aspen found with 2 plates of food inside. Plates were spaghetti and a strong odor  was noted coming from plates. Facility had last had spaghetti greater that 24 hrs prior.  Food was discarded when identified by surveyor.

* Multiple staff members observed to wash hands during meal service in kitchenette sink. There were multiple cups/dishes in the sink while staff members washed hands.

* Dishwasher in Aspen unit observed to have a rack in process that was overcrowded with dishes overlapping others not allowing adequate access for all dishes to be effectively sanitized.

At approximately 2:00 pm, surveyor reviewed above areas with Staff 1 (Executive Director), Staff 3 (Memory Care Administrator) and Staff 2 and they acknowledged the identified areas.

The surveyor toured the kitchenettes in Aspen and Maple units and

observed the following:

"The flooring will be replaced.

"Reach in refrigerators cleaned.

"Weekly cleaning audit log in place.

"Utilize "TempStick" and app to monitor and track refrigerator

temperature.

"Utilize sticker label system to identify and date food. End of day audit logs.

"Training on proper food handling and storage, hand washing protocol.

"Review effective dishwasher uses and cleaning.

Responsible Parties:

The Executive Chef is responsible to monitor the correction of

deficiencies to prevent reoccurrence. The Campus Administrator will

provide oversight and collaboration in all kitchen operations.

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 areas were reviewed on 02/01/24 from 12:50 pm through 2:00 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:

* Drains throughout kitchen;

* Floors throughout the kitchen;

* Reach in coolers/freezers;

* Walk in freezer floor;

* Interior/exterior of microwaves;

* Industrial mixer and table;

* Stainless steel shelving throughout kitchen;

* Interior of drawers where cooking utensils were stored;

* Waffle maker;

* Utility carts;

* Range top, ovens, and grill top;

* Knobs, handles of appliances, and equipment;

* Around edges of hand washing sinks; and

* Reach in coolers with mold build-up on door seals.

b. Multiple kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required.

c. Multiple cutting boards were found heavily scored and stained.

d. Multiple food items found stored open to contamination in walk-in freezer. Multiple food items observed stored without labeling or dating as required. Items noted in fridge stored past seven days.

e. Review of Kitchenettes in Aspen and Maple units found the following:

* Multiple food items stored in reach in refrigerators that were past their used by dates and/or did not contain use by dates or open dates;

* Microwaves found with dried food debris; and

* Reach-in refrigerator and freezer in Aspen with dried food debris.

At approximately 2:00 pm, the surveyor reviewed above areas with Staff 1 (Executive Director) and s/he acknowledged the identified areas in need of correction.  

Kitchen will be maintained in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. 1.Dining staff have assigned cleaning areas to complete daily, weekly, and monthly. These tasks will be signed off and turned into the Dining Services Director or Administrator to confirm completion. Skull caps for all dining staff have been purchased to keep hair effectively restrained. Dining staff will complete additional training on Sanitation and food service. Cutting boards were audited and any with stains and/or heavily scored were discarded and new cutting boards were purchased. Food items in freezer covered and items dated and labeled.

2. Weekly audits of  all kitchen areas will be completed by the Administrator or designee using the State of Oregon kitchen audit tool. Any areas not in compliance will be reviewed with the DSD and Administrator. Corrective action will be taken to ensure continued compliance.

3. Weekly audits will be completed. Further training for Dining Services Director to be provided Feb. 28-Mar. 1 to ensure Dining Service plan of correction is being carried out and all additional training is completed. Training will be provided by company DSD that has passed kitchen survey in the state of Oregon.

4. The Dining Services Director and Memory Care  Administrator will be responsible to see that corrections are completed and are being monitored on an on going weekly basis.

Based on interview and observation, it was determined the facility failed to ensure the kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 240.

Refer to C 240.

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 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:

Refer to C 240.

Refer to C 240.