The findings of the kitchen inspection, conducted 7/10/24, 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 to the kitchen inspection of 07/10/24, conducted 09/06/24, 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 07/10/24, conducted on 11/07/24, are documented in this report. The facility was found 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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:
On 07/10/24 at 10:55 am, the facility kitchen was observed to need cleaning and/or repairs in the following areas:
* Flooring throughout the kitchen - torn, cracked, areas missing the epoxy covering; significant build up of black matter, stains (brown, black, yellow) and debris - under counters, in corners, under dishwashing area, including drain, under and around ice maker, under and around stove/grill/deep fat fryer;
* Walls throughout the kitchen - drips, spills, grease, dust, build up of black/brown matter - in dishwashing area - above and below the counters and behind the dishwashing machine; above and below prep counters; behind and beside the deep fat fryer; behind and beside ice maker;
* Equipment with drips, spills, spatters, food debris, grease, dust - hood vents, microwave oven (interior and exterior), commercial can opener, blender base, exterior of ice maker, front and sides of stove/grill, deep fat fryer;
* Upper and lower shelving throughout the kitchen - food debris, dust, drips, spills, splatters - prep areas, steam table, commercial mixer;
* Kitchen ceiling, vents and sprinkler heads throughout the kitchen, including walk in refrigerator ceiling surrounding the light - significant accumulation of dust;
* Kitchen doors, including walk in refrigerator door - significantly scuffed with black matter; and
* Ceiling light near steam table uncovered exposing light bulb.
Additional observations:
* Two staff not wearing hair/beard restraints.
The above findings were reviewed and discussed with Staff 1 (Director of Food Service) and Staff 2 (Executive Director) on 07/10/24. The findings were acknowledged.
Flooring throughout the kitchen - torn, cracked, areas missing the epoxy covering; significant buildup of black matter, stains (brown, black, yellow) and debris - under counters, in corners, under dishwashing area, including drain, under and around ice maker, under and around stove/grill/deep fat fryer.
a.What action will be taken to correct the rule violation of each example/resident?
b.How will the system be corrected so this violation will not happen again?
c.How often will the area needing correction be evaluated?
d.Who will be responsible to see that the corrections are completed/monitored?
i.Flooring throughout the kitchen cracked, torn, areas missing epoxy covering.
1.Maintenance Director and Assistant will apply new layer of epoxy floor product to seal the cracks and all open areas
2.This will be completed within 14 days of the date of this notice. (completed by 08/08/2024)
3.The floors will be inspected by the Maintenance Director and Assistant monthly the first Thursday of each month following the repairs.
ii.Build up of black matter, stains, and debris under the counters, in corners, under dishwashing area, including drain, under and around ice maker, under and around stove/grill/deep fat fryer.
1.Maintenance Director and Assistant will pressure wash the flooring prior to the application of the epoxy covering.
2.This will be completed within 14 days of the date of this notice. (completed by 08/08/2024)
3.The floors and shelves will be addressed by the Kitchen staff as indicated on the attached daily, weekly and monthly cleaning task lists. (please see attached lists).
4.The Dietary service Director will inspect the Kitchen on a weekly basis every Friday prior to stand-up.
iii.Walls throughout the kitchen - drips, spills, grease, dust, buildup of black/brown matter - in dishwashing area - above and below the counters and behind the dishwashing machine; above and below prep counters; behind and beside the deep fat fryer; behind and beside ice maker.
1.Maintenance Director and Assistant will pressure wash and degrease all walls and surfaces prior to application of the epoxy covering.
2.This will be completed within 14 days of the date of this notice. (completed by 08/08/2024)
3.The walls will be addressed by the Kitchen staff as indicated on the attached daily, weekly and monthly cleaning task lists. (please see attached lists).
4.The Dietary service Director will inspect the Kitchen on a weekly basis every Friday prior to stand-up.
iv. Equipment with drips, spills, spatters, food debris, grease, dust - hood vents, microwave oven (interior and exterior), commercial can opener, blender base, exterior of ice maker, front and sides of stove/grill, deep fat fryer.
1.The Dietary service Director will complete a deep clean of all equipment and surfaces immediately to ensure a clean environment.
2.This is to be completed within 5 days of the date of this notice. (completed by 07/30/2024)
3.The equipment will be addressed by the Kitchen staff as indicated on the attached daily, weekly and monthly cleaning task lists. (please see attached lists).
4.The Dietary service Director will inspect the Kitchen on a weekly basis every Friday prior to stand-up.
v.Upper and lower shelving throughout the kitchen - food debris, dust, drips, spills, splatters - prep areas, steam table, commercial mixer.
1.The Dietary service Director will complete a deep clean of all equipment and surfaces immediately to ensure a clean environment.
2.This is to be completed within 5 days of the date of this notice. (completed by 07/30/2024)
3.The equipment will be addressed by the Kitchen staff as indicated on the attached daily, weekly and monthly cleaning task lists. (please see attached lists).
4.The Dietary service Director will inspect the Kitchen on a weekly basis every Friday prior to stand-up.
vi.Kitchen ceiling, vents and sprinkler heads throughout the kitchen, including walk in refrigerator ceiling surrounding the light - significant accumulation of dust.
1.Maintenance Director and Assistant will pressure wash and degrease all walls and surfaces prior to application of the epoxy covering.
2.This will be completed within 14 days of the date of this notice. (completed by 08/08/2024)
3.Maintenance Director and Assistant will perform monthly maintenance cleanings the first Thursday of each month to maintain cleanliness of high reach areas such as ceilings.
vii.kitchen doors, including walk in refrigerator door - significantly scuffed with black matter.
1.The Dietary service Director will complete a deep clean of all equipment and surfaces immediately to ensure a clean environment.
2.This is to be completed within 5 days of the date of this notice. (completed by 07/30/2024)
3.The equipment will be addressed by the Kitchen staff as indicated on the attached daily, weekly and monthly cleaning task lists. (please see attached lists).
4.The Dietary service Director will inspect the Kitchen on a weekly basis every Friday prior to stand-up.
viii.Ceiling light near steam table uncovered exposing light bulb.
1.The Maintenance Director and Assistant will make repairs to the light/ ceiling prior to application of the epoxy covering.
2.This will be completed within 14 days of the date of this notice. (completed by 08/08/2024)
3.The Dietary service Director will inspect the Kitchen on a weekly basis every Friday prior to stand-up.
ix.Two staff not wearing hair/beard restraints
1.The Dietary Director will perform full in-service training on proper PPE usage in a food service environment within 5 days of the date of this letter. (completed by 07/30/2024)
2.The Dietary Director will do daily inspections to ensure that staff are following state regulations and utilizing PPE appropriately.
Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:
On 09/06/24 at 10:00 am, the facility kitchen was observed to need cleaning and/or repaired in the following areas:
* Flooring throughout the kitchen - torn, cracked, areas missing the epoxy covering; significant build up of black matter, stains (brown, black) and debris - in corners, under dishwashing area, including drain, under and around stove/grill/deep fat fryer;
* Walls throughout the kitchen - drips, spills, grease, dust, build up of black/brown matter - in dishwashing area - above and below the counters and behind the dishwashing machine; behind and beside the deep fat fryer; behind stove; and beside ice maker;
* Equipment with spills, spatters, food debris, grease - front and sides of stove/grill, deep fat fryer;
* Upper shelving on either side of mixer table with dust, food debris;
* Kitchen ceiling, vents and sprinkler heads throughout the kitchen, including walk in refrigerator ceiling surrounding the light - significant accumulation of dust; and
* Kitchen doors to walk in refrigerator and in dry storage area - paint bubbling and peeling off creating an uncleanable surface.
The above findings were observed and discussed with Staff 2 (Manager of the Day) and Staff 3 (Cook) on 09/06/24. The findings were acknowledged.
1.flooring throughout the kitchen - torn, cracked, areas missing the epoxy covering; significant buildup of black matter, stains (brown, black) and debris - in corners, under dishwashing area, including drain, under and around stove/grill/deep fat fryer.
oWhat actions will be taken to correct the rule violation?
oThe flooring will be removed and replaced by a professional flooring company.
oHow will the system be corrected so this violation will not happen again?
oThe flooring will be replaced with a more durable product and maintained daily.
oHow often will the area needing correction be evaluated?
oIt will require daily cleaning and inspection to ensure it remains in good condition.
oWho on your staff will be responsible to see that the corrections are completed/monitored?
oThe evening cook will be responsible for the cleaning of the floors.
oDate facility alleges compliance.
o10/21/2024
2.Walls throughout the kitchen - drips, spills, grease, dust, buildup of black/brown matter - in dishwashing area - above and below the counters and behind the dishwashing machine; behind and beside the deep fat fryer; behind stove; and beside ice maker.
oWhat actions will be taken to correct the rule violation?
oThe kitchen will continue to be cleaned according to the daily, weekly, and monthly cleaning schedules. (see attached document).
oHow will the system be corrected so this violation will not happen again?
oKitchen will continue to be cleaned according to the daily, weekly, and monthly cleaning schedules (see attached document).
oHow often will the area needing correction be evaluated?
oThe dining service director will walk the kitchen daily while on duty to ensure cleanliness.
oWho on your staff will be responsible to see that the corrections are completed/monitored?
oDining service director
oDate facility alleges compliance.
o10/21/2024
3.Equipment with spills, spatters, food debris, grease - front and sides of stove/grill, deep fat fryer.
oWhat actions will be taken to correct the rule violation?
oKitchen will continue to be cleaned according to the daily, weekly, and monthly cleaning schedules (see attached document).
oHow will the system be corrected so this violation will not happen again?
oKitchen will continue to be cleaned according to the daily, weekly, and monthly cleaning schedules (see attached document).
oHow often will the area needing correction be evaluated?
oThe dining service director will walk the kitchen daily while on duty to ensure cleanliness.
oWho on your staff will be responsible to see that the corrections are completed/monitored?
oThe dining service director
oDate facility alleges compliance.
o10/21/2024
4.Upper shelving on either side of mixer table with dust, food debris.
oWhat actions will be taken to correct the rule violation?
oKitchen will continue to be cleaned according to the daily, weekly, and monthly cleaning schedules (see attached document).
oHow will the system be corrected so this violation will not happen again?
oKitchen will continue to be cleaned according to the daily, weekly, and monthly cleaning schedules (see attached document).
oHow often will the area needing correction be evaluated?
oThe dining service director will walk the kitchen daily while on duty to ensure cleanliness.
oWho on your staff will be responsible to see that the corrections are completed/monitored?
oThe dining service director
oDate facility alleges compliance.
o10/21/2024
5.Kitchen ceiling, vents and sprinkler heads throughout the kitchen, including walk in refrigerator ceiling surrounding the light - significant accumulation of dust; and
oWhat actions will be taken to correct the rule violation?
oMaintenance department will remove and clean all vents, ceiling, and around all sprinklers monthly.
oHow will the system be corrected so this violation will not happen again?
oThis will be added to the monthly tasks assigned to the Maintenance department.
oHow often will the area needing correction be evaluated?
oMonthly on the first week of each month.
oWho on your staff will be responsible to see that the corrections are completed/monitored?
oDirector of plant maintenance.
oDate facility alleges compliance.
o10/21/2024
There are no detail notes for this visit.
Based on interview and observation, 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.
See C 240
There are no detail notes for this visit.