The findings of the kitchen inspection, conducted 6/30/23-7/3/23, 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 first re-visit to the kitchen inspection of 06/30/23, conducted 10/5/23, 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 second re-visit to the kitchen inspection of 06/30/23, conducted 01/11/24, 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, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the kitchen on 6/30/23 at 10:30 am through 12:30 pm revealed the following deficiencies:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Flooring in freezer room;

* Flooring in corners, edges, between and under equipment;

* Interior of Ice machine;

* Ceiling, vents and fire sprinklers;

* Drains throughout kitchen;

* Industrial can opener and housing;

* Interior of microwave;

* Interiors of cupboards/cabinets and drawers;

* Interior of resident refrigerator;

* Interior of freezer;

* Range top, grill, and interior of ovens;

* Grill and oven knobs;

* Floor between oven and side tables with food debris;

* Ceiling above ovens:

* Walls throughout kitchen and food storage areas;

* Area behind and under dishwasher; and

* Hand washing sink and surrounding area.

b. The following areas were found in need of repair:

* Cabinets under 3 compartment sink with damaged/rotting wood;

* Wood cabinets throughout kitchen with areas needing repaired or painted;

* Section of caulking behind sinks with black matter buildup;

* Wood pallet under ice machine causing un-cleanable area.

* Vents and fire sprinklers with heavy dust/dirt buildup;

* Cabinet areas stained or cracked or chipped; and

* Door thresholds with damaged/exposed wood.

c. Cutting boards were observed heavily stained and scored. Spatulas also found chipped and stained.

d. Facility did not have test strips available to validate concentration of sanitizer used for surface sanitation buckets and 3 compartment sinks, or dish machine.

e. Dish machine was not registering any chemical to sanitize dishes. Surveyor tested dish machine with chlorine and quat test strips. Neither one registered any concentration. Per staff 2 (Dinning Service Manager) the chemical for machine was chlorine. S/He validated there were no strips on hand and was shown test strips and validated no chemical sanitizer was registering. Staff 2 indicated the facility would utilize a 3 sink method until dish machine representative could service the machine.

f. Kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required.

g. Hand washing sink was directly by a food prep or service area and did not have a splash guard to prevent possible contamination of food or area by hand washing.

h. Dish washing racks were observed stored on the floor.

i. Scoops were found stored in multiple bulk food items/bins.

Surveyor reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas.  On 7/3/23 at 12:00 pm the surveyor reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Administrator). S/he acknowledged the areas.  

C240: OAR 411-054-0030

Immediate Correction Plan - The DSD immediately cleanedup all food spills, splatters, loose food and trash debris, dirt,dust and grease on the day of the survey visit from DHS on 6-30-23. The flooring in the freezer room was scoured and cleaned on 7-1-23. The interior of the ice machine has also been cleaned to satisfactory level.The sink stains throughout he kitchen have been scoured to the best of the DSD's ability. The microwave has been disposed of and we will be purchasing a new one by 7-24-23. The interior of cabinets/cupboards and drawers have been cleaned. Interior

of resident refrigerator has been cleaned. Interior of freezer has been cleaned. The range top, grill, and interior of ovens.The grill and oven knobs have been cleaned. The floors have scrubbed and cleaned to best of the DSD s ability.Walls throughout kitchen and food areas have been scrubbed down. Area behind and under dishwasher have been cleaned. The hand washing sink and surrounding area have been cleaned. Cutting boards have been replaced. Spatulas have been ordered. ProGuard will be in this week, est: by 7-21-23 to give us test strips for the dishmachine in order to validate concentration of sanitizer used for surface sanitation buckets or 3 compartment sinks and/or dish machine. Dish machine was repaired due to not registering any chemical to sanitize dishes. Per stated above, we are awaiting test strips and are

,using the 3 sink method until we receive them from ProGuard. Immediately, the kitchen staff is wearing proper hair nets/facial hair nets as required.  

Intermediate - black matter will need deep cleaning and will be completed by 7-21-23. This will entail thorough deep cleaning of the comers of the floor, stainless steel deep cleaning and polishing of all stainless surfaces. The ceilings and vents have been cleaned to the best of the DSD and kitchen staff. We are waiting on commercial fire to come and clean the sprinkler heads. We made our first attempt on 6-30-23; another attempt was made on 7-18-23. Our ETA for lthe sprinkler cleaning completion 8-18-23.The industrial can opener is on backorder from Sysco. Cabinets are in need of repair; we are in the process of obtaining 3 quotes for the cabinets under 3 compartments sink with damaged/rotting wood. These areas need repaired/painted. This will be under corporate approval for the job completion process as they need to approve the labor/cost of the replacement of the cabinets. The expected date of approval and completion onthe cabinets is 8-18-23 depending contractors and bids. The section of the caulking will need some work and we expect Ito have this completed by 7-21-23. Wood pallet under ice machine has been removed. This has been covered previously and we are awaiting the fire company to service the sprinker heads. Cabinets stained, cracked and/or chipped 1will be replaced by ETA of8-18-23. Door thresholds will be replaced at the time of the cabinet replacement, see above; ETA 8-18-23. Along with the cabinet replacement, a splash guard will be installed to prevent splashing or contamination of food. Immediately, dishwashing racks are no longer stored on the floor. They will be kept on the bin rack.

Immedately, the scoops were removed from food bins. Long Term - In order for the kitchen to remain at it's best, lthe DSD has created and will immedately train/implement as well as create a long term plan. He has created a "Cleaning Task List", see below:

Weekly Tasks:

1.All Shelving

a.Clean under steam table

b.Clean under island

c.Clean all sinks

d.Clean inside all of the kitchen cabinets

2.       Dry Storage/ floor cleaning

3.Freezer Room - Sweep & Mop

4.Wipe down refrigerator and freezers

5.All cabinets/faces of cabinets

6.Hoods/Hood Vents

7.Drains - To remain clean at all times; clean if necessary There is also a "Daily Task List" for the cooks/kitchen staff which will be monitored and supervised by the DSD/ED on an ongoing basis

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, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the kitchen on 10/5 at 11:30 am through 12:30 pm revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Flooring in freezer room;

* Flooring in corners, edges, between and under equipment;

* Ceiling, vents and fire sprinklers;

* Drains throughout kitchen;

* Industrial can opener and housing;

* Interior of microwave;

* Interiors of cupboards/cabinets and drawers;

* Interior of resident refrigerator;

* Interior of freezer;

* Range top, grill and interior of ovens;

* Grill and oven knobs;

* Walls throughout kitchen and food storage areas;

b. The following areas were found in need of repair:

* Vents and fire sprinklers with heavy dust/dirt buildup;

c. Multiple items in reach in refrigerator were not dated and/or labeled as required.

d. Food contact equipment were not stored correctly to prevent potential contamination during storage. Forks/ knives/spoons were stored with food contact surfaces up and exposed to possible contaminants.

e. A container of half and half was found past the manufactures use by date.

f. Kitchen staff  were observed preparing and/or serving food without their hair and/or facial hair effectively restrained as required.

g. Hand washing sink was observed directly by a food prep/service area, where clean dishes (silverware and plates) were stored and no splash guard present to prevent possible contamination of food/area/equipment by hand washing.

h. Dish washing racks were observed stored on the floor.

i. Scoops were found stored in multiple bulk food items/bins.

The surveyor reviewed the above areas with Staff 1 (Administrator) and s/he acknowledged the identified findings.  

1.All areas of the Kitchen will be cleaned from ceiling to floor, in the main kitchen, the dry storage room as well as the refrigerator room. Inside cabinets, drains, drawers all will be emptied and cleaned. Grill and oven will be cleaned. Vents & sprinklers will be cleaned. The fridge will be cleaned out. Food equipment storage will be reviewed and corrected. All food will have an open date and be gone through weekly to ensure nothing has expired. All staff will wear hairnets and have facial hair restrained. A new handwashing sink has been ordered and will be in place. Storage for dish racks has been addressed and they will remain off the floor. Scoops will not be stored in bins.

2. In-service will occur the week of 11/6/23 for proper food handling and sanitation standards - full kitchen cleaning will occurr the week of 11/6/23 after new counters, sink and cabinets are installed.

Task sheets put into place to ensure cleaning tasks are not fallen behind on.

3.The Director of Dining Services will be responsible for monitoring cleanliness & ensuring task sheets are completed daily/weekly

4. Training and competency evaluation for kitchen staff and direct care staff on kitchen and kitchenette cleanliness and food service. Dining Service Director will oversee dining service and cleanliness. Administrator will do weekly sanitation, food service audit and observation.

Based on interview, observation, and record review, it was determined the facility failed to ensure their Kitchen sanitation survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C240.

1. Interim ED in place will conduct weekly sanitation and cleanliness audits & communicate with DHS if we are unable to comply by 11/19/23 & need any more time.

2. In-service will occur the week of 11/6/23 for proper food handling and sanitation standards - full kitchen cleaning will occurr the week of 11/6/23 after new counters, sink and cabinets are installed.

Task sheets put into place to ensure cleaning tasks are not fallen behind on.

3.The Director of Dining Services will be responsible for monitoring cleanliness & ensuring task sheets are completed daily/weekly

4. Training and competency evaluation for kitchen staff and direct care staff on kitchen and kitchenette cleanliness and food service. Dining Service Director will oversee dining service and cleanliness. Administrator will do weekly sanitation, food service audit and observation.

Based on observation, record review 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 C 240.

see C 240

Based on observation, record review 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.

1.All areas of the Kitchen will be cleaned from ceiling to floor, in the main kitchen, the dry storage room as well as the refrigerator room. Inside cabinets, drains, drawers all will be emptied and cleaned. Grill and oven will be cleaned. Vents & sprinklers will be cleaned. The fridge will be cleaned out. Food equipment storage will be reviewed and corrected. All food will have an open date and be gone through weekly to ensure nothing has expired. All staff will wear hairnets and have facial hair restrained. A new handwashing sink has been ordered and will be in place. Storage for dish racks has been addressed and they will remain off the floor. Scoops will not be stored in bins.

2. In-service will occur the week of 11/6/23 for proper food handling and sanitation standards - full kitchen cleaning will occurr the week of 11/6/23 after new counters, sink and cabinets are installed.

Task sheets put into place to ensure cleaning tasks are not fallen behind on.

3.The Director of Dining Services will be responsible for monitoring cleanliness & ensuring task sheets are completed daily/weekly

4. Training and competency evaluation for kitchen staff and direct care staff on kitchen and kitchenette cleanliness and food service. Dining Service Director will oversee dining service and cleanliness. Administrator will do weekly sanitation, food service audit and observation.