The findings of the kitchen inspection, conducted 07/07/22, 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 07/07/22, conducted 10/04/22, 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 07/07/22, conducted 12/13/22, 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 ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 07/07/22, the main kitchen was observed to need cleaning and repair in the following areas:

a. The dish washing station was noted with:

* The dish machine, electrical box, walls, floor, shelving, ceiling grate, and pipes under the dish machine and sinks had an accumulation of black matter, debris and food matter;

* Dish racks were stored directly on the floor; and

* The dish machine utilized a low temperature rinse cycle with chlorine to sanitize dishes. There were no sanitizer strips available to ensure the correct chemical levels.

The surveyor toured the dish washing station with Staff 1 (Executive Director). She acknowledged the need for cleaning and arranged for sanitizer strips to be acquired.

b. The following was observed in the main areas of the kitchen:

* Floors throughout the kitchen had thick black matter build-up and food debris in corners, under equipment, and around edges/inside of floor drains;

* Spills, smears, splatters, and debris were noted on:

-Carts,

-Drawers interior and exterior;

-Cupboards interior and exterior;

-Walls;

-Freezer and refrigerator doors, handles, and venting fans;

-Ceilings throughout the kitchen;

-Counters;

-Shelves;

-Stove, grill,and range;

-Steam table;

-Plate warmer;

-Food bins;

-Stand mixers;

-Microwave interior; and

-Underneath appliances;

* Food was stored on the floor of the refrigerator and the freezer;

* Multiple food items in the refrigerator had dates in excess of seven days;

* Cupboards, shelves, and counter tops were damaged creating un-cleanable surfaces;

* The vents and ceiling grates had a layer of dust and dirt;

* A large industrial fan had a layer of dust on the cage;

* Garbage cans in food prep and storage areas lacked lids;

* Dented can of food noted in they dry storage area; and

* Stove hood vents had a layer of grease and dust;

Caregiving staff assisting with meal service and delivery on 07/07/22 were not using aprons and dietary staff were observed during meal preparation on 07/07/22 to not change gloves or practice hand hygiene between tasks.  

Infection control practices and the areas in the kitchen needing cleaning and repair were observed and reviewed with Staff 1 on 07/07/22. She acknowledged the findings.

The kitchen is scheduled to be deep cleaned. The Hood has already been cleaned and is now set on a regular schedule. Ordered stickers to ensure of proper dates and making sure all food is stored and removed properly. PSI has been here to fix the hood and is not cleared. Maintenance director and DSM have come up with an ordering system to ensure all chemicals and testing supplies are in the facility. ED went over with maintenance director on the areas that needed cleaned and repaired. All vents are scheduled to be taken down after kitchen hours and cleaned. ED and DSM have met with all staff on proper use of aprons in the kitchen.

DSM, ED meet weekly to ensure things are getting repaired and cleaned properly. DSM is to report when repairs are needed promptly via Electronic Maintenance systems. DSM is creating charts for all staff for follow.

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

On 10/04/22, the dish machine was observed in operation.

The dish machine utilized a low temperature rinse cycle with chlorine to sanitize dishes. The sanitizer was tested with the available strips and the chemical level was noted out of the required range. There was no documented evidence of monitoring of the sanitizing solution or accurate monitoring of the dish machines temperature.  

The surveyor reviewed the need to ensure correct sanitizer solution and temperature monitoring with Staff 1 (Executive Director) and Staff 2 (Dietary Manager). They acknowledged the findings.

The following was observed in the main areas of the kitchen:

* Floors throughout the kitchen had black matter build-up and food debris in corners, under equipment, on cove base, and around edges/inside of floor drains;

* Spills, smears, splatters, and debris were noted on:

-Carts,

-Walls;

-Back of grill and side of range;

-Food bins;

-Stand mixer;

-Microwave interior; and

-Underneath appliances;

* Food was stored on the floor of the refrigerator and the freezer; and

* Dented can of food noted in they dry storage area.

The areas in the kitchen needing cleaning and repair were observed and reviewed with Staff 1 and Staff 2 on 10/04/22. They acknowledged the findings.

Tag C240 Will be corrected by cleaning all areas of the kitchen including but not limited to the floor edges and molding, the back walls, and vents. All Kitchen Equipment is on a schedule to be cleaned whether it' s used or not. Vents are on a new cleaning schedule and to be followed up by DSM. DSM has implented new temp and chemical logs and has full access to print all logs when needed and is to keep all records up to date. All Dented cans have been removed and will never be placed in the working area. DSM ED meet weekly to go over all forms to make sure they are in compliance.

Based on interview and record review, 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.

POC  C 455 submitting POC today and will ensure all POC's in the future are timely.