The findings of the kitchen inspection, conducted 02/13/24, 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 first revisit kitchen inspection to the relicensure inspection of 02/13/24 conducted 05/14/24 through 05/15/24, 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 re-visit to the kitchen inspection of 02/13/24, conducted on 07/16/24, 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 ensure the kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:

On 02/13/24 at 11:05 am, the kitchen was observed in need of cleaning in the following areas:

* Pots and pans' finish worn off; hotel pans and sheet pans had a heavy build-up of grease and black matter;

* Lower shelves throughout the kitchen had black shelf liners on them which were covered with debris;

* Flooring throughout the kitchen and under shelves, stove, refrigerator, freezer, sinks, and dry storage had debris and black matter;

* The drain under the dishwashing area had black matter build-up;

* The commercial can opener;

* The oven doors and interior of the ovens;

* The fan on window sill had heavy dust build-up;

* The open window screen had a build-up of cobwebs and an opening to the outdoors; and

* A screen on the wall above the microwave had a build-up of black matter.

The following areas were in need of repair:

* Missing equipment covers below the oven doors, which were exposing wires and had a build-up of debris; and

* Garbage disposal not working and had food build-up in drain.

In addition:

* One garbage can was uncovered when not in use;

* The facility did not have chemical test strips for the dishwasher; and

* Staff were not always washing hands between glove changes.

The areas of concerns were observed by and discussed with Staff 1 (Dietary Manager) and discussed with Staff 2 (Executive Director) on 02/13/24. The findings were acknowledged by both staff.

1.The following actions wil1 be taken to correct the violations:

a.Kitchen equipment that was identified that were worn off like pots and pan, hotel pans, sheet pans with heavy build-up grease and black matter, commercial can opener and fan on the window sill with heavy dust will be replaced with a brand new equipment.  

b.Community Kitchen including all areas identified that needed cleaning like flooring throughout the kitchen, drain under dishwashing area, oven doors, shelves and window will be cleaned by the kitchen staff and housekeeping.

c.The kitchen equipment that were identified that needed repair like the oven door and garbage disposal will be repaired by the Maintenance technician or an outside company.

d.The open garbage can was replaced with garbage can with lid, community purchased chemical test strips for the dishwasher.

e.All staff will be provided an in-service training regarding safe food handling practices and infection control procedures, including proper hand washing/sanitizing to avoid cross-contamination during food preparation and meal services.

2.) The systems will be corrected by the following:

a.The Executive Director has created a cleaning checklist, including daily, weekly, and monthly scheduled tasks, to ensure that food and sanitation protocols are in accordance to the Oregon Food Sanitation Rules. Executive Director and Maintenance Technician will complete visual checks of the kitchen for potential needs for repair and replacing equipment every quarter and as needed.

b.All staff will continue to receive biannual training on safe food handling practices and infection control procedures. New employees will receive this training as part of the pre-service requirements, in addition to scheduled biannual training courses.

3.) The systems to ensure that food and kitchen sanitation in accordance with the Oregon Food Sanitation Rules, including cleaning, repairs, proper safe food handling practices, and infection control procedures, will be evaluated by the Executive Director monthly during monthly Management Meetings.

4.) The Executive Director will be responsible for overseeing that the above systems are in place and continuously monitored.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner and good repair 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 main kitchen and second floor kitchenette on 05/14/24 and 05/15/24 identified the following:

a. The following areas were in need of cleaning and/or repair in the main kitchen on the first floor:

* The flooring and wall beneath the warewashing area had a buildup of debris, brown and black matter, food crumbs and broken dishware;

* Floor baseboard coving was missing in the dry food storage area and back of kitchen where pots/pans were stored;

* Exterior screen door leading to the secured resident patio was unlocked and had gaps around the door frame and holes in the screen, which allowed for the entry of pests;

* Two covers were missing below the Imperial oven doors which exposed electrical wires;

* Sanitation buckets were not in use and staff were unaware of where the test strips were and how to use them;

* A cook was not using gloves as single use between touching different food items and was not washing hands between glove changes;

* The reach-in freezer was not cooling/maintaining proper temperature -food had thawed and was discarded during the survey;

* Improper shelving of food product in the reach- in refrigerator (ready to eat meat was stored with thawing raw meat, eggs were shelved with meat product, meat was shelved above raw vegetables); and

* Reach-in freezer and refrigerators in the main kitchen had a buildup of food splatter and food debris on the interior shelves and exterior.

b. The following areas were in need of cleaning and/or repair in the kitchenette on the second floor:

* Cabinet door hinge was broken which impeded the ability to close the door;

* Black matter buildup in and around the caulking of the counter were the counter and wall joined;

* Caulking around the sink where the sink basin and counter top joined was missing;

* Peeling paint and/or veneer on multiple areas of the cabinets which exposed wood beneath; and

* The refrigerator interior and exterior had a buildup of food debris and splatters.

The need to ensure the kitchen was maintained in accordance with the Food Sanitation Rules was discussed with Staff 1 (ED) and Staff 2 (Health Services Director) on 05/15/24. They acknowledged the findings.

A. 1.The following actions will be taken to correct the violations:

a. Community kitchen including all areas identified for cleaning like the flooring and wall beneath the washing area build-up of debris, brown and black matter, food crumbs and broken dishware will be cleaned by the kitchen staff and housekeeping as per cleaning schedule.

b. Floor baseboard coving was missing in the dry good storage area and back of the kitchen where pots and pans are stored. Base board coving will be installed throughout the dry storage area by the maintenance technician.

c. Exterior screen door leading to the secured resident patio was unlocked and had gaps around the door frame and holes in the screen which allowed for entry of pests. Screen door will be replaced with a brand new screen door.

d. Two covers were missing below the imperial oven which exposed electrical wires. The covers will be replaced by an outside company.

e. Sanitation buckets were not in use and staff were unaware where the test strips were and how to use them. All kithcen staff will be trained on how to use the sanitation buckets and test strips by Shamrock Supply Company.

f. All Kitchen staff; cook and dietary aides will be provided an in-service training regarding safe food handling, proper glove and proper hand washing/ sanitizing to avoid cross contamination during food preparation and cooking.

g. The reach-in freezer was not cooling/ maintaining proper temprature. The community brought 2 new upright freezer to replace the reach-in freezer.

h. Proper food shelving with the reach-in refrigirator was  re- organized by raw meat at the bottom of the shelf, produce  are were on the top shelf and milk, cheese egg & ready to eat  products are on the middle shelf.

i.  Reach-in refrigirator and freezers interior shelves and exterior doors are scheduled to be cleaned once a week and as needed of food splatter and food debri.

B. The following areas were in need of cleaning or repair in the kitchenette 2nd floor:

a. Cabinet door hinge was brokenm which impeded the ability to closeethe door. The cabinet door was fixed and in working condition.

b. Black matter build up and around the caulking of the counter where the counter and wall ajoined. The caulking on the counter was cleaned and replaced.

c. Caulking around the sink where sink basin and counter top joined was missing. The caulking around the sink and basin will be replaced/ repaired.

d. Peeling paint and/or veener on multiple areas of the cabinet which exposed wood. The cabinet will be repaired and repainted.

e. The refrigirator interior and exterior had a buildup of food debris and splatters. The refrigirator interior and exterior was cleaned by kitchen staff and housekeeper.

2. The systems will corrected by the following:

The Executive Director has created a cleaning checklist, including daily, weekly, and monthly scheduled tasks, to ensure that food and sanitation protocols are in accordance to the Oregon Food Sanitation Rules. Executive Director, Dining Manager and Maintenance Technician will complete visual checks of the kitchen for potential needs for repair and replacing equipment every quarter and as needed.

b.   All Kitchen  staff will continue to receive biannual training on safe food handling practices and infection control procedures. New employees will receive this training as part of the pre-service requirements, in addition to scheduled biannual training courses.

3.) The systems to ensure that food and kitchen sanitation in accordance with the Oregon Food Sanitation Rules, including cleaning, repairs, proper safe food handling practices, and infection control procedures, will be evaluated by the Executive Director monthly during monthly Management Meetings.

4.) The Executive Director and Dining Manager will be responsible for overseeing that the above systems are in place and continuously monitored.

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. Findings include, but are not limited to:

Refer to C 240 and Z 142.

Refer to response on C240 and Z140.

Based on observation and interview, it was determined the facility failed to provide effective administrative oversight over the operation of the kitchen and kitchenettes. Findings include, but are not limited to:

During the first revisit to the annual kitchen inspection of 02/13/24, conducted 05/14/24 through 05/15/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number of repeat citations and areas of deficiency within the kitchen that had not been resolved.

During an interview with Staff 1 (ED) on 05/14/24 it was reported the kitchen had two staff who rotated cooking throughout the week. Currently, there was no administrative staff for the kitchen.

Refer to C240 and Z142.

1. The following actions will be taken to correct the violations:

Community failed to provided effective adminitrative oversight over the operation of the kitchen and kitchennette.

2. The systems will be corrected by the following:

The Executive Director will promote within or hire a dining manager that will provide oversight in the operations of the kitchen and the kitchennettes.

3.)The systems to ensure that the operation of the kitchne and kitchnnette will be in accorordance of food and kitchen sanitation rules with the Oregon Food Sanitation Rules, including cleaning, repairs, proper safe food handling practices, and infection control procedures, will be evaluated by the Executive Director, Dining Manager monthly during monthly Management Meetings.

4.) The Executive Director and Dining Manager will be responsible for overseeing that the above systems are in place and continuously monitored.

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 C240.

Refer to C240 Response.

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 & Z140  Response.