The findings of the kitchen inspection, conducted 01/10/23, 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 1/10/23, conducted 4/14/23, 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 maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

On 01/10/23 at 09:40 am, food storage, prep and service areas were toured with designated Person In Charge (PIC) Staff 2 (Head Cook). Kitchen areas in cottages 610, 611, and 612 were observed to need cleaning and repairs in the following areas:

* Kitchen cabinet exteriors throughout all kitchens had multiple spills, smears, splatters, and sticky surfaces. Majority of kitchen cabinet exterior surfaces were also worn and damaged, and one drawer in cottage 611 had two holes. Maintenance Manager contacted Staff 2 and was told that work to refurbish all cabinets will be handled internally and was scheduled to start on 01/23/23;

* Kitchen cabinet interiors in all kitchens were found dirty with sticky black residue;

* A utensil storage drawer in cottage 611 was damaged;

* Door hinges inside kitchen cabinets and under sinks in all kitchens were covered with grease, dust, and dirt, presenting risk for cross-contamination of clean kitchenware stored in cabinets;

* The floor in cottage 611 had food debris, dirt, and unidentified yellow powdery substance spilled in the corner;

* Two drawers under the oven in cottage 610 had brown liquid spills;

* Corner of swinging door to kitchen in cottage 611 was covered with cloth and masking tape. Staff 2 was unsure of reason for this mitigation or repair;

* Microwave interiors, doors and handles in cottages 610 and 612 had food debris and splashes;

* Exterior of water dispensers in all reach in refrigerators were dirty and covered with white residue. Staff 2 was unaware of schedule for replacing water filters;

* Interior of dishwasher in cottage 610 was dirty and covered with white residue;

* Rack for clean dishes in cottage 612 was dirty;

* Coffeemaker in cottage 611 was stained and dirty with splatters;

* Toaster in cottage 612 was dirty and covered with food residue;

* Exterior of refrigerator in cottage 612 had missing or broken control buttons;

* Interior of stove exhaust hoods in cottages 610, 611 and 612 was covered with grease and layered with dust;

* A gap in wall was noted under the sink where garbage disposal outlet pipe went through wall in cottage 612;

* Cutting boards in all kitchens were found heavily scored and/or stained;

* Ceiling vents in all kitchen areas were dirty and covered with dust; and

* Electrical outlets were covered with dust/dirt/debris.

On 01/10/23 at 10:10 am, the storage house that included a dry storage area with shelving, standard kitchen sink, a walk-in cooler and reach-in refrigerator was toured and observed to need cleaning and repairs in the following areas:

a. Walk-in cooler:

* Area under metal shelves had pooled liquid;

* Surface of door near outside door handle was dirty;

* Two circulating fans were covered with dust and dirt, blowing dust throughout cooler. Portion of dust collected on pipes on ceiling; and

* Multiple metal shelves with peeling paint and rust.

b. Reach-in refrigerator:

* Circulation fan in reach-in refrigerator was covered with dust;

* Interior door frame was dirty; and

* Racks had areas of dirt and rust. There were portions of racks that had protective coating peeled off or missing.

c. Dry storage area with shelving and kitchen sink:

* Plastic cover of ceiling light fixture was cracked;

* Air conditioning ceiling vent was covered with dust;

* Light switches on wall next to shelf were covered with blue masking tape;

* Cooking vessels were stored under sink next to cleaning products;

* Surface of storage drawers had chipped and peeling paint;

* Wall by reach in refrigerator was dirty; and

* Wood shelving and drawers were found with damage and dust/dirt/debris accumulation.

On 01/10/23 at 10:35 am, the dry storage room was toured and observed to need cleaning and repairs in the following areas:

* Shelving cracked, damaged and worn with rough and soiled surfaces;

* Broom was stored directly on the floor;

* Gaps in wall around air conditioner wall unit, allowing outside air/contaminants and potential pests to enter through gap;

* Air conditioner wall unit vent was covered with dust; and

* Dust and cobwebs found in corners and edges.

On 01/10/23 at 10:45 am, a room with four upright freezers was toured and observed to need cleaning and repairs in the following areas:

* Molding of door frame inside room was removed, exposing underlying wall construction;

* Ceiling vent covered with dust;

* All four freezers had substantial build-up of frost;

* Vegetable freezer had a spill on an interior door shelf; and

* Gap in ceiling noted around yellow vertical pipe.

On 01/10/23 at 11:55 am, kitchen staff was observed not following proper hygienic practices:

* One kitchen staff was observed not using gloves properly by loading food onto cart, entering door access code while transporting food, and plating food at destination while using same pair of single-use gloves.

On 01/10/23 at 09:40 am, the following improper food handling practices were observed:

* Yogurt stored in the reach-in refrigerators in cottage 610 was found not dated when opened;

* Milk and butter in the reach-in refrigerators in cottage 612 were found not dated when opened;

* Unidentified liquid was stored in a disposable coffee cup in the reach-in refrigerator in cottage 611;

* Open/damaged container of breadcrumbs found on storage shelf; and

* Two coffee jars had scoops placed inside.

On 01/10/23 at 11:55 am, the following improper food service practices were observed:

* A caregiver transported an uncovered plates of food from the kitchen to multiple residents rooms;

* Hot food item (enchiladas) was at a temperature of 130 degrees F prior to serving; and

* Cold food item (flan) was found at 50 degrees F during service.

Also, kitchen in cottage 611 did not have test strips for checking sanitizers available. Staff 2 said that she had strips available in the storage house. Kitchen in cottage 612 sanitizer strips were noted open to air resting in cook cart. Staff 2 acknowledged they should not be stored that way. Administration had no fixed cleaning schedule.

The findings were discussed with Staff 1 (Administrator), Staff 2 (Head Cook), and Staff 3 (Assistant Administrator) on 01/10/23 at 12:40. Staff acknowledged the findings.

1) All observances of rule violations listed in the SOD were compiled into a list. From this list, all deficiencies have been addressed and will be brought back into compliance.

2) Majority of the observances were issues with cleanliness and minor repairs. Housekeeping and maintenance, cleaning, and repair schedules have been updated and are now reflective of the areas that need attention. A kitchen audit/quality control form has been implemented and will be filled out weekly. A policy and procedure manual for how to clean specific items is being compiled.

For the observances that were items that needed to be replaced (such as shelving and freezer racks), new items or parts have been ordered.

Please see the attachment for specific observances and the correction.

3) Depending on the issue, items will be addressed weekly, monthly or (in cases such as the deep cleaning of the stove hoods) every 6 months or as needed.

4) Administrator, Maintenance Director, Kitchen Director

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.

see C240