The findings of the kitchen inspection, conducted 04/03/24, 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 04/03/24, conducted 07/09/24 through 07/10/24, 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 second revisit to the kitchen inspection of 04/03/24, conducted 09/05/24, 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 third re-visit to the kitchen inspection of 04/03/24, conducted on 10/30/24, 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 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 04/03/24 at 11:15 am, the facility kitchen was observed to need cleaning in the following areas:

a. Food spills, splatters, debris, dirt, dust, grease and/or black/brown matter was observed on or underneath the following:

* Bottom shelf of the counter top refrigerator next to coffee maker; - food debris/spills on bottom shelf, freezer with significant ice buildup;

* Vents below the doors of refrigerators #2 and #4;

* Bottom shelves and vents below the doors of Freezers #1 and #2;

* The oven doors and sides of stove/grill;

* The hood vents above the stove/grill;

* The lower shelves of counters and preparation areas throughout the kitchen including:

  - counters next to stove/grill;

  - holding mixer attachments;

  - cupboards with doors in front of steam table holding clean dishes;

  - under steam table;

* Walls and ceiling throughout the kitchen including:

  - in the dishwashing area below the rack shelf;

  - behind the spray hose and dishwasher;

  - wall area above and below counter holding blenders next to the stove/grill;

  - wall surrounding handwashing sink behind the stove wall & underneath sink areas;

  - wall area behind the three sink area;

  - above the window air conditioner;

  - wall next to the exterior door;

  - ceiling vents above steam table; and

  - pan storage area;

* Window air conditioner, which was in operation (blowing air) creating potential for cross contamination;

* Food slicer and holding shelf beneath the slicer; and

* Flooring throughout the kitchen, including: dry storage area; dishwashing area; corners and underneath counters and storage shelves.

b. Other findings included:

*Freezer #1 - not all food items were frozen solid, temperature at 30 degrees F;

* Refrigerators #2, #4 and freezer #1 contained containers and repackaged food items which were unlabeled/undated (imitation crab; pears; cut fruit; lunch meat; cheese slices);

* Cardboard boxes of disposable containers and foil sheets were stored on the floor in dry storage area; and

*One uncovered garbage can.

The findings were discussed with Staff 1 (Med Tech serving as kitchen PIC), Staff 2 (Executive Director) and Staff 3 (ALF Administrator) on 04/03/24. The findings were acknowledged.

A deep cleaning of all kitchen areas identified has been completed as of 4/17/2024 by all kitchen staff.

A daily cleaning log for all kitchen areas identified has been re-established and is placed in a binder for staff to initial as they are completed.  The Food Service Director is responsible for ensuring this is completed daily and in her absence, the responsibility is that of the Lead cook. The Executive Director is responsible for auditing that this is completed weekly. In the absence of the ED, the Administrator of the AL will be responsible.

An audit of the kitchen using the CBC audit form will be completed weekly by the Food Service Director.  The Executive Director is responsible for auditing that this is completed weekly. In the absence of the ED, the Administrator of the AL will be responsible.

The Maintenance Director has removed, cleaned and repainted the vents and is responsible for observing these monthly to ensure they are not in need of repair. The Executive Director is responsible for auditing that this is completed. In the absence of the ED, the Administrator of the AL will be responsible.

Items were removed from Freezer, temped, and prepared in proper time to ensure no food-borne illnesses occurred on 04/03/2024. Freezer was repaired on 4/5/2024 and a temperature log is located in the kitchen to ensure the temperature of all refrigerators and freezers are at temperature and keeping the food cold.  An internal thermometer was placed in all refrigerators, and this will be used for documentation rather than the exterior digital thermometers to ensure that the proper temp is kept and documented. This in-service with all kitchen staff will be completed by 5/1/2024

All kitchen staff will be retrained on labeling/dating opened food, cleaning lists, food and dry storage not being placed on the ground, lids on garbage cans always.  Cleaning lists will be reviewed, and all staff agree that they understand the cleaning expected of them and the proper documentation of cleaning completed and temperatures for both food, dishwasher, and refrigerator/freezers.  This in-service with all kitchen staff will be completed by 5/1/2024.

Crandall Dietitians will be completing quarterly audits of facility kitchen and serving in the dining room as well as special diets. These will be reviewed with Food Service Director and Executive Director.

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

On 07/09/24 at 9:30 am, the facility kitchen and memory care kitchenette were observed.

a. Food spills, splatters, debris, dirt, dust, grease and/or black/brown matter was observed on or underneath the following:

* Bottom shelf of the counter-top refrigerator next to coffee maker;

* Stainless steel shelving, racks and carts throughout the kitchen;

* The oven doors and sides of stove/grill;

* The lower shelves of counters and preparation areas throughout the kitchen;

* Stand mixer and mixer attachments;

* Cupboards with doors in front of steam table holding clean dishes;

* Shelving under steam table;

* Walls and ceiling throughout the kitchen;

* Light switch in dry storage room;

* Paper towel dispenser near coffee station; and

* Flooring throughout the kitchen.

b. Items in need of repair included:  

* Ceiling areas throughout the kitchen had unsealed drywall and unfilled cracks or holes;

* Cabinet containing clean dishes had corner laminate pieces missing which made the cabinet an uncleanable surface; and

* Cutting boards had deep scratches and were scored.

c. Other findings included:

* Window air conditioner and two industrial fans, which were in operation (blowing air), were covered with dirt and debris creating the potential for cross contamination;

* Refrigerators contained food items which were unlabeled and/or undated (lunch meat and cheese);

* Bins in the dry storage room containing oatmeal, brown sugar, and rice were unsealed and open to air;

* Two uncovered garbage cans; and

* Two staff were not wearing hair restraints.

d. Kitchenette findings included:

* Unfinished cabinetry, which made the cabinets uncleanable surfaces, had staining.

The findings were discussed with Staff 5 (Executive Chef), Staff 2(Executive Director) and on 07/10/24 at 1:15 pm. The findings were acknowledged.

1. a. A deep clean of the kitchen was conducted on all areas listed in the SOD.

b. The ceiling was repaired, cutting boards were discarded and new boards ordered, laminate was repaired on cabinet.

c. Window air conditioner was cleaned.  The industrial fans were removed.  Refrigerators were cleaned and all food was labeled, dated, and/or discarded. Retraining was completed for all kitchen staff and care-staff regarding use of hair restraints, ensuring the garbage cans are covered at all times.  d. Cabinet was repaired with new laminate to ensure that there are no uncleanable surfaces.

2. Daily (by shift) cleaning logs have been reviewed by all staff and will be completed each shift.  Environmental Services will complete a weekly walk-through and ensure there are no unfinished surfaces or building deficiencies needing addressed.

3.  This will be audited weekly by the Food Services Director.

4. The Food Services Director and Executive Director will be responsible for ensuring these corrections are completed/monitored.  

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

On 09/05/24 at 11:40 am, the facility kitchen and memory care kitchenette were observed, and the following was identified:

* Floors throughout the kitchen had black matter build-up, food debris, and grease in corners, under equipment, and around perimeter edges;

* Missing and damaged chunks of flooring were noted in the dishwashing area, under the ice machine, refrigerator, and freezer;

* The wall behind the dishwashing area had black stains;

* The caulking in the dishwashing area and behind the preparation counter had an accumulation of brown and black stains; and

* The cabinets containing clean dishes had chipped and missing laminate with exposed porous wood areas.

Kitchenette findings included:

* Unfinished cabinetry, which made the cabinets uncleanable surfaces, had staining.

On 09/05/24 at 1:30 pm, the findings were discussed with Staff 1 (MT), Staff 2 (Executive Director), Staff 4 (Assisted Living Administrator) and Staff 5 (Executive Chef). They acknowledged the findings.

Based on observation and interview, 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

Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240.

Based on observation and interview, 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 C240.

Please see our plan of corrections at C240

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240.

See C 240

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240.