The findings of the kitchen inspection, conducted 09/13/22, 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 09/13/22, conducted 12/01/22, 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 09/13/22, conducted 04/07/23, 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 and interview, the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.

Upon entering the facility on 09/13/22, multiple direct care staff were observed not wearing medical face masks. Several staff were observe in cloth face masks that were below their nose and chin.

In an interview with Staff 1 (Executive Director) on 09/13/22, he indicated all staff should be wearing face masks. He was not aware of the requirement for medical masks. He acknowledged the findings.

OAR 411-054-0025 (4) Reasonable

Precautions

1. Actions taken to correct the rule violation for each example/resident are as follows:

   a. All staff in all departments have been trained on use of medical face masks per OAR 333-019-1011 (6), (8), and (10).

 2. How will system be corrected so this violation will not happen again are as follows:

  a. Visual checks on use of medical face mask by staff.

3. How often will the area needing correction be evaluated are as follows:

 a. Daily when working

4.  Who will be responsible to see that the corrections are completed/monitored are as follows:

a. Each department supervisor will conduct visual checks daily when working.

b. Department supervisor will report to ED on staff compliance

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 09/13/22 the kitchen was toured with Staff 1 (Executive Director) and Staff 2 (dietary Manager). The following areas of concern were identified:

* Flies were observed throughout the kitchen;

* Floors throughout the kitchen, including walk-in refrigerator and freezer, food prep areas, behind and underneath ovens and appliances, had an build-up of black matter, grease, and food debris;

* Pipes, walls, gauges, disposal, drain, and flooring behind/underneath the dish machine and three compartment sinks were covered in black matter, grease, and corrosion. The caulking in the dish machine area was discolored and in disrepair;

* Pipes beneath cupboards and behind ice machine were covered with a layer of dirt, dust, and lint;

* Walls and ceilings throughout the kitchen had multiple spills, smears, and food splatters;

* Stainless steel shelving, shelf legs, and beneath shelving throughout the kitchen had spills, splatters, and debris;

* Cups and scoops were left in the food in bulk food bins. The bins had spill, splatters, and debris;

* Garbage cans throughout the kitchen area were uncovered, food debris and spills stuck to the outside of containers;

* Exterior of ovens were covered in grease, food spills, orange and black sticky build up;

* Interior of ovens and deep fat fryer had a buildup of burnt food debris, grease, splatters, and spills;

* The blade of the can opener had a build up of black matter;

* The stand mixers had spills, splatters, and dried on food;

* Uncovered, undated, and unlabeled food items were noted in the walk-in refrigerator and freezer. A serving spoon was left in a bin of cut fruit;

* Rolling carts throughout the kitchen had loose food debris, spills, splatters, and stuck food matter;

* Multiple dented cans and an uncovered tray of croutons were noted in the dry food storage area;

* Kitchen staff were observed not wearing face masks properly;

* Garbage cans were not available at the hand washing sinks;

* Dish machine racks were observed stored directly on the floor;

* The high temperature dish machine was observed in operation and failed to reach the required temperature; and

* There were not test strips available to monitor the sanitizer bucket solution.

There was no monitoring of the temperatures of:

* The dish machine;

* Food temperatures on the tray line; and

* The refrigerator.

The need to ensure the kitchen was maintained in a sanitary manner and food was stored and prepared in accordance with the Food Sanitation Rules, OAR 333-150-000, was discussed with Staff 1. He acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident

Services Meals, Food Sanitation Rule

1. What actions will be taken to correct the rule violation for each example/resident are as follows:

a. Pest control has been contacted and appropriate action taken for flies removal and prevention

b. Floors throughout the kitchen and in the following areas have been cleaned to remove black matter, grease, and food debris: walk-in refrigerator and freezer, food prep areas, behind and underneath ovens and appliances

c. Pipes, walls, gauges, disposal, drain,

and flooring behind/underneath the dish machine and three compartment sinks cleaned of black matter, grease, and corrosion. Caulking in the dish machine area was removed and repaired;

d.Pipes beneath cupboards and behind ice machine were cleaned of dirt, dust, and lint;

e.  Walls and ceilings throughout the

kitchen have been cleaned of multiple spills, smears, and food splatters;

f. Stainless steel shelving, shelf legs, and

beneath shelving throughout the kitchen

have been cleaned of spills, splatters, and debris;

g.  Cups and scoops removed from bulk food bins.    

h. Bins cleaned of spill,splatters, and debris;

i. Garbage cans lids throughout the kitchen purchased and in place

j. Food debris and spills stuck to the outside of garbage containers have been cleaned

k. Exterior of ovens were cleaned of grease, food spills, orange and black sticky build up;

l. Interior of ovens and deep fat fryer cleaned of buildup of burnt food debris, grease,splatters, and spills;

m. The blade of the can opener cleaned of build up of black matter;

n. Stand mixers cleaned of all spills, splatters, and dried on food;

o. All food has been covered, dated, and labled with removal of any serving spoons

p. Rolling carts throughout the kitchen

cleaned of loose food debris, spills, splatters,

and stuck on food matter;

q. Dented cans and an uncovered tray of croutons removed from the dry food storage area;

r. Kitchen staff trained on wearing face masks -see C160

s. Garbage can now available at the hand washing sinks;

t. Dish machine racks located in alrernate area so as not to be stored directly on the floor;

u. High temperature dish machine

repair took place on 9/14/22 .Test strips purchased and available to monitor the sanitizer bucket solution.

v. Temperature monitoring of the

of the following have been implemented and trained on: dish machine; food temperatures on the tray line; and the refrigerator.

 2. How will the system be corrected so this violation will not happen again are as follows:

a. Cleaning schedule, and temperature logs implemented

b. food safety training on kitchen sanitary practices and food storage/preparation in accordance with the Food Sanitation Rules, OAR 333-150-000 has been done with staff.  

c. All dining/kitchen staff trained on audit tools, and cleaning schudules

3. How often will the area needing correction be evaluated are as follows:

a. Daily when working by Culinary Director

b. Weekly by ED or designee  

 4. Who will be responsible to see that the corrections are completed/monitored are as follows:

a. Culinary Director or designee

b. ED or designee   

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 12/1/22 the kitchen was toured with Staff 1 (Executive Director). The following areas of concern were identified:

* Pipes, walls, gauges, disposal, drain, and flooring behind/underneath the dish machine and three compartment sinks were covered in black matter, grease, and corrosion. The caulking in the dish machine area was discolored and in disrepair;

* Spills, splatters, and debris were noted on the magnetic knife holder, the bakery sheets and racks, and the stand mixers;

* Uncovered, undated, unlabeled, expired foods, and foods dated past seven days were noted in the deli refrigerator, walk-in refrigerator, and freezer;

* Raw meat was stored above vegetables in the walk in refrigerator;

* A used serving spoon was left on a serving tray in the walk in refrigerator;

* Items were stored on the floor in the walk in freezer;

* Condiments labeled "Refrigerate after opening" were stored outside the refrigerator;

* Cups and scoops were left in the food in bulk food bins. The bins had spill, splatters, and debris;

* Multiple open packages of food were noted in the dry food storage area; and

* There were not test strips available to monitor the sanitizer bucket solution.

The need to ensure the kitchen was maintained in a sanitary manner and food was stored and prepared in accordance with the Food Sanitation Rules, OAR 333-150-000, was discussed with Staff 1. He acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

1.What actions will be taken to correct the rule violation for each example are as follows:

a.Pipes, walls, gauges, disposal, drain,

and flooring behind/underneath the dish

machine and three compartment sinks

were cleaned and degreased of black matter, grease, and corrosion.

b.The caulking in the dish

machine area has been removed and re-caulked.

c. Spills, splatters, and debris were cleaned

on the magnetic knife holder, the bakery

sheets and racks, and the stand mixers.

d. Uncovered, undated, unlabeled,

expired foods, and foods dated past

seven days were removed from the deli

refrigerator, walk-in refrigerator, and

freezer.

e. Raw meat storage has been corrected in the walk-in refrigerator.

f.used serving spoon removed from serving tray

g.Items that were stored on the floor in the

walk in freezer have been moved;

h.Condiments left out and that were labeled "Refrigerate after opening" were disposed of

i.Cups and scoops that were left in the food

in bulk food bins have been removed.

j.Bins have been cleaned of spill, splatters, and debris.

k. Multiple open packages of food that were noted in the dry food storage area have been removed.

l.Test strips to monitor the sanitizer bucket solution available to staff and location reviewed vs being kept in CD office

2.How will the system be corrected so this violation will not happen again are as follows:

a.New Culinary Director will complete food safety training on kitchen sanitary practices and food storage/preparation in accordance with the Food Sanitation Rules, OAR 333-150-000

b.Mentor assigned to new Culinary Director

c.All dining/kitchen staff trained on audit tools, and cleaning schudules

3. How often will the area needing correction be evaluated are as follows:

a. Daily when working by Culinary Director

b. Daily when working walk through to be completed by ED or designee to meet with CD on compliance

 4. Who will be responsible to see that the corrections are completed/monitored are as follows:

a. Culinary Director or designee

b. ED or designee   

Based on observation and interview, it was determined the facility failed to ensure their relicensure 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