The findings of the kitchen inspection, conducted 01/02/24, 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 01/02/24, conducted 03/15/24, 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 01/02/24, conducted 05/17/24, 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 01/02/24, conducted 07/12/24, are documented in this report. 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 the kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 01/02/24 at 11:00 am, the kitchen was observed to need cleaning in the following areas:

a. Food spills, splatters, debris, dust, grease and/or black matter were observed in the following areas:

* Reach in refrigerator - bottom shelf and exterior doors;

* The cove base of flooring under the front of the steam table, in corners, and along the wall to the dining room;

* Dishwashing room: black matter on the caulking and wall above the back splash around the sink area;

* Ceiling vent and ceiling area around the vent in the dishwashing room;

* Vents are both sides of the hood;

* Dust accumulation throughout the kitchen on the following items:

 - Clock above the door;

 - Hand sanitizer dispensers;

 - Fire suppression tanks;

 - Thermostat;

 - Wall vent between the walk in refrigerator and dry storage room;

 - First aid kit;

 - Biohazard response box; and

 - Ceiling pipes in the prep area and above the door to the outside.

b. Kitchen staff not wearing hair restraints.  

c. Garbage cans uncovered when not in use.

The areas of concern were discussed with Staff 1 (Dietary Serviced Director), Staff 2 (Sous Chef) and Staff 3 (Administrator Designee) on 01/02/24. The findings were acknowledged.

This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 01/02/24 at 11:00 am, the kitchenwas observed to need cleaning in the following areas: a. Food spills, splatters, debris, dust, grease and/or black matter were observed in the following areas: * Reach in refrigerator - bottom shelf and exterior doors; * The cove base of flooring under the front of the steam table, in corners, and along the wall to the dining room; * Dishwashing room: black matter on the caulking and wall above the back splash around the sink area; * Ceiling vent and ceiling area around

the vent in the dishwashing room; * Vents are both sides of the hood; * Dust accumulation throughout the kitchen on the following items:

- Clock above the door;

- Hand sanitizer dispensers;

- Fire suppression tanks;

- Thermostat;

- Wall vent between the walk in

refrigerator and dry storage room;

- First aid kit;

- Biohazard response box; and

- Ceiling pipes in the prep area and

above the door to the outside.

b. Kitchen staff not wearing hair

restraints.

c. Garbage cans uncovered when not in

use.

*Kitchen special cleaning was completed on 01/04/2024 to address findings of dust and debris throughout areas of the kitchen.

*DSD/Sous Chef have updated it's cleaning list to encompass all of the areas found to be neglected and are tasked with weekly oversight.

*In-service training will be conducted on every third Tuesday of each month to address areas of improvement and conduct sanitation training including hairnets.

*Kitchen has ordered garbage can lids and are awaiting delivery.

*Dining has added an additional supervisor to assist in overall operation and sanitation.

*Dishwashing room issues are to be remedied by Maintenance Director no later than 03/02/2024

The Executive Director or designee will be responsible for overseeing that the corrections are completed and monitored.   

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. This is a repeat citation. Findings include, but are not limited to:

Observations of the kitchen on 03/15/24 identified the following:

a. Food spills, splatters, debris, dust, grease and/or black matter were observed in the following areas:

* The cove base of flooring under the front of the steam table, in corners, and along the wall to the dining room; and

* Walls and backsplash of the dishwashing room.

b. Dust accumulation throughout the kitchen on the following items:

* Clock above the door; and

* Hand sanitizer dispensers.

c. Kitchen staff were not wearing hair restraints.  

d. Garbage cans were uncovered when not in use.

e. Cleaning and Repair:

* There was a piece of wood covering the ceiling above the exit door to the dining room;

* There were four lights in the prep area and two lights in the dry storage area that were not working;

* There was a broken light cover in the dry storage area;

* There was a built up of debris and chipped paint on the door going into the walk in refrigerator; and

* There was an accumulation of ice along the top and sides of the door to the walk in freezer.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 2 (Dining Services Director) and Staff 3 (ED) on 03/15/24. They acknowledged the findings.

1.  

Food spills, splatters, debris, dust, grease and black matter will be addressed by the following:

*The cove base of flooring under the front of the steam tables, in corners and along the wall to the dining room and the walls and backsplash of the dishwashing room will be professionally cleaned and power washed by 4/29/2024.

Dust accumulation throughout the kitchen on the clock and the hand sanitizers have been cleaned.

Areas in need of cleaning and repair will be addressed by the following:

* Ceiling drywall, door to the walk in refrigerator and lights in need of replacement will be repaired by the Maintenance Technician by 4/29/2024.

* A quote to replace the broken lens covers has been obtained and work will conclude by 4/29/2024.

* Equipment has been ordered to repair the freezer causing an accumulation of ice build-up with expected installation completion by 4/29/2024.

2.

Kitchen staff were educated on the importance of covered trash receptacles and use of hair restraints on 3/25/2024.  

Current staff will be educated on reporting areas in need of repair through use of the community work order system by 4/9/2024.

A kitchen cleaning schedule is in place to assure that cleaning tasks are being completed.  Kitchen staff have been educated on the schedule as of _4/2/2024_____.

3.

Executive Director or designee will review the cleaning checklist for completion a minimum of 4 days per week for the next 60 days.  A weekly walk through of the kitchen and serving area will be completed by the Dining Service Manager and/or Maintenance Technician to validate effectiveness of cleaning.

4.

The Executive Direcotr, Dining Services Manager and the Maintenance Technician are responsible for this plan of correction.

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. This is a repeat citation. Findings include, but are not limited to:

Observations of the kitchen on 05/17/24 identified the following:

a. Garbage cans were uncovered when not in use.

b. Kitchen staff were not wearing hair restraints.  

c. There was a thick accumulation of ice along the top and sides of the door to the walk in freezer preventing it from being able to close or latch.

d. The door to the walk in cooler was damaged and did not close or latch.

e. Both the walk in cooler and freezer had multiple boxes of food stored directly on the floor.

f. The dry storage area had cardboard boxes stored directly on the floor.

g. The dry storage area floor had a puddle of water approximately 5' x 3' in one corner, and another behind the door, soaking the cardboard boxes stored on the floor.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 3 (Administrator). She acknowledged the findings.

This Rule is not met as evidenced by: 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. This is a repeat citation. Findings include, but are not limited to:

a. Garbage cans were uncovered when

not in use.

-All garbage cans have lids, staff trained on covering trash can when not in use.

b. Kitchen staff were not wearing hair

restraints.

-All staff trained on when to use hair restraints. Signs posted with hair restraint location in kitchen.

c. There was a thick accumulation of ice

along the top and sides of the door to the

walk in freezer preventing it from being

able to close or latch.

-The freezer has been repaired to prevent ice from accumilating and preventing the freezer from closing properly.

d. The door to the walk in cooler was

damaged and did not close or latch.

- The latch has been reapired so door closes properly. Sign posted on door reminding staff to make sure door is fully shut.

e. Both the walk in cooler and freezer

had multiple boxes of food stored directly

on the floor.

-All food in walk in and freezer is stored properly and off of the floor. Staff trained on proper food storage.

f. The dry storage area had cardboard

boxes stored directly on the floor.

- All food and other supplies are stored off of floor and properly. Staff trained on proper stroage of dry food and goods.

g. The dry storage area floor had a puddle of water approximately 5' x 3' in one corner, and another behind the door, soaking the cardboard boxes stored on the floor.

-AC unit that was leaking has been repaired.

The Executive Director or designee will be responsible for overseeing that all corrections are completed and monitored.   

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

Refer to C 240.

Refer to plan of correction for C240

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection 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.

Refer to C 240.