The findings of the kitchen inspection, conducted 08/11/22, 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 Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen survey of 08/11/22, conducted 11/22/22, 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 11/22/22, conducted 2/3/23, 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 third revisit to the kitchen inspection of 08/11/22, conducted 04/27/23, 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, it was determined 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.
During observations of the ALF main kitchen on 08/11/22 between 11:00 am and 3:45 pm, multiple kitchen and serving staff were observed not wearing masks properly, exposing their noses and mouths.
The need for the facility to ensure all staff consistently follow current masking requirements was reviewed on 08/11/22 at 2:30 pm with Staff 2 (Dining Services Coordinator) and with Staff 1 (Executive Director) at 2:45 pm. They acknowledged the findings.
1) Kitchen staff have been in-serviced and re-trained to wear their masks and keep them pulled up while in the community
2) Dining Service Director will hold kitchen staff accountable to keep their masks on and pulled up while in the community.
3) Daily
4) Dining Services Manager. Executive Director when the Dining Services Manager is not on duty.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, food was prepared properly and surfaces were sanitized, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
Observations of the ALF main kitchen, food storage areas, food preparation, and food service on 08/11/22 revealed:
* The following areas needed cleaning or repair:
- The walls and ceiling of the janitor closet had been removed, exposing pipes, bare wood and metal wall studs;
- There was a large area of floor under the three-compartment sink where tiles had been removed and covered with plywood;
- There was black mold on the wall above the warewashing wash area; and
- There were pieces of old food floating in the water of the steam table troughs.
* Splatters, spills, drips or debris were observed on:
- Floors throughout the kitchen, walk-in refrigerator and walk-in freezer;
- Multiple floor drains;
- The tops of the bread oven and steamer;
- Lower shelves under the steamer, steam table and rear prep counter where cutting boards were stored;
- Wire storage racks in the walk-in refrigerator;
- Steel and plastic serving carts;
- The interior of the microwave oven;
- The can opener blade;
- Multiple blenders and food processors;
- The meat slicer; and
- A ceiling vent over the janitor's closet and the grates of the fans in the walk-in refrigerator.
* Plastic bins of oat flakes in the dry storage room were uncovered and oats had been spilled on lower shelves and the floor.
* Desserts in the walk-in refrigerator (pies, cookies, fruit cups) were not covered to protect from contaminants.
* Several containers of food in the walk-in refrigerator were not fully sealed. Opened or leftover food items that were stored in the refrigerator were not consistently dated.
* An employee's sweatshirt was tossed on a wire shelving unit used to store bakeware.
* Wet rags with visible debris were left laying on counters. Staff were observed wiping down counters later without rinsing the rags in a sanitizing solution.
* A staff person was observed handling clean dishware without having sanitized his hands after previously handling soiled items.
* Staff 3 (Cook) failed to check the temperature of fried veal cutlets to determine if they had reached the proper internal cooking temperature.
The areas needing cleaning and repair, and the failure to follow safe food handling and preparation practices was reviewed on 08/11/22 at 2:30 pm with Staff 2 (Dining Services Coordinator) and with Staff 1 (Executive Director) at 2:45 pm. They acknowledged the findings.
The community has instituted a cleaning schedule touching all topics referenced in the SOD, that all kitchen staff have been trained on by the Dining Service Coordinator.
Kitchen staff will sign off on the training and mark off cleaning tasks as completed.
All noted maintenance items in SOD have been repaired and in good working order and cleanliness.
2) The Dining Service Coordinator will monitor the cleaning schedule and hold ktichen staff accountable, re-train and audit as needed to ensure quality control.
3) Evaluated and audited daily.
4) Dining Services Coordinator for all mentioned cleaning and training items. Maintenance Director for all mentioned maintenance and repair items.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
Observations of the ALF main kitchen and food storage areas on 11/22/22 identified the following deficiencies:
* Splatters, spills, drips or debris were observed on:
- Floors throughout the kitchen, walk-in refrigerator and walk-in freezer;
- Wire storage racks in the walk-in refrigerator;
- The can opener blade; and
- Inside of plate warmer cabinet.
* Plastic bins of oat flakes in the dry storage room were uncovered and oats had been spilled on lower shelves and the floor.
* An employee was seated and eating a meal in the dry storage room; and
* An employee's thermal lunch container was stored in the walk-in refrigerator.
The areas needing cleaning and the failure to follow safe food handling and preparation practices was reviewed on 11/22/22 with Staff 5 (Executive Director). He acknowledged the findings.
Facility will provide written training to all dining staff with the cleaning schedule, touching on all parts noted in re-survey.
Dining Services Manager will audit the memory care kitchen, food storage, and dining areas and the signed cleaning log daily.
Daily
Dining Services Manager
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:
Observations of the ALF main kitchen and food storage areas on 2/3/23 identified the following deficiencies:
* Splatters, spills, drips, dust and/or debris were observed on:
- Floors behind, underneath and beside equipment and open shelving;
- Vents and fire sprinklers;
- Grill top, back splash and behind grill;
- Stove top, exterior and interior of regular and convection ovens;
- Ceiling and wall of walk in cooler;
- Cooling fan covers in freezer;
- Walls behind juice machine and by entrance/exit door to dining room;
- Open shelving above steam table and where spices were stored;
- The can opener blade and casing;
- Interior and exterior of microwave and toaster; and
- Inside of plate warmer cabinet.
* There were 2 holes observed under a prep area table. They were acknowledged by Staff 1 (Executive Director). There was significant ice build up on the door to the walk in freezer, in the walk in freezer as well and noted dripping and rusting areas in the walk in cooler. A large section of exposed pressed wood by a window seal was observed from the smooth cleanable surface pealing off.
* Multiple items in walk in cooler found not labeled or dated.
* Multiple items in walk in cooler found uncovered.
* Multiple employees found not washing hands when entering kitchen area as well as not washing hands when changing from dirty tasks to clean tasks.
* Kitchen staff observed to heat up a can of tomato soup and did not check the temperature before serving to resident.
* Lunch item temperatures were not checked prior to start of service. They were removed from convection oven, placed in steam table, covers removed and staff served residents. Temperature logs were reviewed and multiple days of food temperatures were not recorded. Staff 1 (Executive director) and Staff 2 (Dining Services Coordinator) acknowledged temperatures were not recorded.
* Cleaning task list and schedule was reviewed with Staff 2 and she validated multiple days were missing documentation. She did state that staff frequently forget to write it down.
* Plan of correction presented by facility included weekly audits. Staff 1 was asked for documentation that audits had been conducted and none was provided.
The areas needing cleaning and the failure to follow safe food handling and preparation practices was reviewed on 2/3/23 with Staff 1 (Executive Director). He acknowledged the findings.
Facility will implement Brookdale Menu Manager menus approved by Crandall Corporations Dieticians as well as real time trainings with kitchen staff. Will follow the Daily Diet Modification sheets. Will provide mid morning, mid afternoon, and evening snacks daily.
Utilization of proper portioning serving tools to monitor correct servings of food served
Menus will be planned at least 2 weeks in advance and provide residents their copies of the menus.
Any substitution will be recorded on the Menu Substitution Log
Dining Services Manager, Interim Director, Memory Care Administrator
will monitor compliance by doing daily documented audits.
Educating our Dining associates by inservices and actual real time trainings in Food safety and sanitation.
ALF Main Kitchen
Cleaning Schedule is in place.
- Floors have been cleaned and is maintained by following cleaning schedules daily. Sweep and mop every after meal or as needed.
- Maintenance have scheduled clean up and repairs of vents and fire sprinklers.
- Scrubbed, clean and maintaining oven, grill and stovetop area by schedule, done daily by designated associate.
- Finished cleaning cooler ceiling and walls. Scheduled cleaning is in place, or clean as needed.
- Maintenance contacted repair company to fixed freezer/cooler.
- Walls behind juice machine cleaned and being maintained daily.
- Open shelving for spices is now organized and being maintained daily
- Ordered new can opener to be installed
- Microwave in brand new and daily clean up is part of assigned cleaning schedule
- Scrubbed and cleaned plate warmer. Daily clean up is part of assigned cleaning schedule
- 2 holes have been patched and will be painted
- Replaced pressed wood with real wood and will be painted
- Dining Leader continues to monitor practice of proper dating and food labeling - inserviced culinary associates.
- Spot audits are being done by different department heads to ensure compliance in food safety and sanitation.
- Proper heating of RTE food addressed. Instructed servers to request assistance from the cooks to properly take temperatures of any food before serving
- Inservices going on for proper food holding temperatures of cold and hot foods. Taking and documenting internal temperatures of food to know if temperatures are correct before placing in steam table. Taking temperatures of food before start of meal service and every 30 mintes thereafter. Hot food should be kept hot, cold foods cold.
- Temperature Logs are in place. Dining Leader monitors and inforce daily
Continually training and coaching associates to be compliance in Food Safety and Sanitation.
There are no detail notes for this visit.
Based on observation and interview, it was determined 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.
During observations of the ALF main kitchen on 11/22/22 between 11:55 am and 12:30 pm, multiple kitchen staff were observed not wearing masks properly, exposing their noses and mouths.
The need for the facility to ensure all staff consistently follow current masking requirements was reviewed with Staff 5 (Executive Director). He acknowledged the findings.
Facility will provide written counselling to the staff observed not wearing a mask properly, and written training to all staff regarding mask expectations.
Written training will be provided to all memory care staff, and enforced daily
The memory care community will be walked daily, and staff on duty observed to ensure masks are being worn properly.
Executive Director
There are no detail notes for this visit.
Based on interview and observation, 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 and C 295.
Please refer to C240
Based on interview, observation and review of documentation, 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 C240.
Refer to C 240
There are no detail notes for this visit.